University of Connecticut Health Center Library
Proxy Registration Form
for
Off-Campus Graduate Students Registered for Classes at UCHC


Please provide the following information in order to apply for UCHC library borrowing and electronic library access privileges as an Off-Campus Graduate Students Registered for Classes at UCHC. If you prefer, you may submit your information via e-mail.


Patron Name: *

E-mail Address: *


UCHC Course name/number: *

Instructor's name: * (The instructor will be contacted to verify your registration in this course)

Instructor's UCHC phone number:


Home Address: * Apt. No.

City: * State: * ZIP code: *

Home Phone No. : *


Work Address:

City: State ZIP code

Work Phone No.: *


* I accept the UConn Health Center Library Terms of Use

The fields with "*" are required fields.

The information required in this application is necessary in order to comply with electronic database licensing requirements and to limit library borrowing privileges to those who are part of the UCHC community.

Send questions to Circulation Department at circ@nso.uchc.edu