ACCESS CARD AUTHORIZATION FORM

* Date:

Access Needed Until: _ 12/31/2009 _ 07/31/2009

* Name:

* Address:

* City, State, Zip:

* Phone:

* Drivers License #

To qualify for an Access Card, requestor must demonstrate one of the following:

1. Proof of affiliation with Loyola. For example, working with a Loyola researcher, consulting with a Loyola physician, practicing health care provider/librarian at a Loyola affiliated hospital (proof of employment is required), graduate of LUMC Residency program, spouse or child of a Loyola employee or alumni.

2. The resources the user wishes to consult are unique to Loyola and unavailable at other metropolitan Chicago health sciences libraries.

Access card permits the bearer use of Library materials and photocopiers within the confines of the Health Sciences Library. Reference services, interlibrary loan, use of reserve collections and other materials or services with restricted access or use are not extended to Access card holders. Access card holders are required to use the main Reading Room only.

Please answer all that apply

If working with a Loyola Researcher or consulting with a Loyola Physician, give name & phone of the researcher or physician:

If working at a Loyola affiliated hospital, please identify the hospital:

If you need to use any resource unique to Loyola, please idenitfy the resource:

Other (please specify):

Return to: Administrative Secretary, Health Sciences Library, Loyola University of Chicago, 2160 S. 1st Ave, Maywood, IL 60153, with a copy of your driver's license.

Approval:_________________________________

Received by_____________________ Comments_________________________________________

* Indicates Response Required

ACCESS CARD AUTHORIZATION FORM

Access Needed Until: ___ 12/31/2009 ___ 07/31/2009

Please answer all that apply

Access Needed Until: _ 12/31/2009 _ 07/31/2009