= Required

Name
	First:		Last:
Primary Mailing Address
	Street (Apt/Rt/Suite #):
	City/State/ZIP:
	Campus/Work Address
	Department & Institution's Name:
	Street (Apt/Rt/Suite #):
	City/State/ZIP:
Contact Information
	Day Phone:		Evening Phone:
	Pager:		Fax:
	Email:
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:
Faxed or mailed forms should be signed. By typing name here you are electronically signing.
OSU-CHS Affiliation
	(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.