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Center for Health Sciences
Application for Library Privileges
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Circulation | Interlibrary Loan | Photocopying | Reference | Application for Library Privileges

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Name
  First:   Last:
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Primary Mailing Address
  Street (Apt/Rt/Suite #):    
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  City/State/ZIP:    
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  Campus/Work Address    
  Department & Institution's Name:    
     
       
  Street (Apt/Rt/Suite #):    
     
       
  City/State/ZIP:    
     
       
Contact Information
  Day Phone:   Evening Phone:
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  Pager:   Fax:
   
       
  Email:    
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By signing this form I have read and agree to the terms listed in the OSU Center for Health Sciences Medical Library’s policies. I am responsible for all materials borrowed and for charges made when material is damaged, lost, or returned late. I acknowledge that the library items will not be loaned to me without presenting my library card. I recognize that a replacement value of one dollar will be expected to issue any subsequent library cards.
       
  Signature:    
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Faxed or mailed forms should be signed. By typing name here you are electronically signing.
       
OSU-CHS Affiliation
Required field (Please check one)    
  CHS Faculty    
  CHS Staff    
  CHS Preceptor/Volunteer    
  CHS Intern/Resident - State D.O.    
  CHS Medical Student    
  Other (Please explain)    
     
  Non-OSU affiliated patrons may be subject to a yearly membership fee. Please contact the Library for information.