Proxy Borrower Authorization Form

Western Libraries Proxy Borrower Authorization Form

Responsible Patron:		Campus Address: (Department & Mail Stop)
Campus Phone:		Home Phone:

Proxy Borrower's Name:		Expiration Date of Proxy 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 Wilson Library. 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. I have read and agree to the Responsibility Statement