UNIVERSITY OF CONNECTICUT HEALTH CENTER
LIBRARY
LOANSOME DOC REGISTRATION
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:
WARNING CONCERNING COPYRIGHT COMPLIANCE
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 ill@nso.uchc.edu
DK Nov 2005