Name ___________________________________________________________________

Business Name (for business accounts) __________________________________________

Address _________________________________________________________________


Telephone (____) ____________ Fax (_____) ____________ e-mail __________________

Occupation/Type of Business ________________________________________________

Method of Payment (choose one):

_____ Deposit Account:

($100 minimum for individual health practitioners: $600 minimum+ $25 annual service fee for businesses) Make check payable to: University of Connecticut Health Center Library

_____ Charge: Circle one: MasterCard or VISA

Account number: ________________________________ Expiration:_______

Security Code (the last three digits printed on the back of your card): ___________

If your credit card is billed to an address that differs from your mailing address, please supply mailing (street address or Post Office Box) and zip code

Mailing address _______________________________________________ Zip Code ____________

_____UCHC Dept. Coding (UCHC Fac/Staff) _____/_____________/___________

Please read the following and sign below:
The copyright law of the United States (Title 17, United States Code) governs the making of photocopies or other reproductions of copyrighted materials. Under certain conditions specified in the law, libraries and archives are authorized to furnish a photocopy or other reproduction. One of these specified conditions is that the photocopy or reproduction is not to be "used for any purpose other than private study, scholarship or research." If a user makes a request for, or later uses, a photocopy or reproduction for purposes in excess of "fair use", that user may be liable for copyright infringement. This institution reserves the right to refuse to accept a copying order if, in its judgment, fulfillment of the order would involve violation of the Copyright Law.

Signature _______________________________________ Date_______________________

Return this form to:

University of Connecticut
Health Center Library
Loansome Doc Registration
P. O. Box 4003
Farmington, CT 06034-4003


Charge card or FRS users may fax to (860) 679-4046.
If you have any questions our voice phone is (860) 679-2940 and our e-mail is

DK Nov 2005


Loansome Doc Information