Western Libraries Proxy Borrower Authorization Form

Responsible Patron: *

Email Address:

Campus Address:

Include your Department and Mail Stop

Campus Phone:

Home Phone:

Proxy Borrower's Name:

Start Date of Borrower's Affiliation:

End Date of Borrower's Affiliation: *

Responsibility Statement:

I authorize Proxy Borrower above to borrow books under my name, in my absence, at the Circulation Services Desk of Western Libraries. I understand that the proxy will be required to show their own piece of picture identification. I accept full responsibility for any books borrowed by my proxy during the authorized period of affiliation.

Agreement: *

By checking this box I confirm that I have read and agree to the Responsibility Statement above.

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Math question: * 1 + 4 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.