Cat Registration

To Be Printed OUT and returned to the Library
The George T. Harrell Library Registration Form
Mail Code : H127
PENN STATE MILTON S. HERSHEY MEDICAL CENTER
Please PRINT Clearly:

Name: _____________________________________________________________________________
First Middle Last

Penn State Access Account User ID _____________ (Example: fjw2 )

PSU ID Number (from new PSU ID+ cards) : 9__ __ __ __ __ __ __ __

Degree, Certification, or Licensure: ___________________________

PSU/HMC Department: _____________________________________

Department MAIL CODE ________________________________

Email Address: ______________________________ (MANDATORY)

Lab or Department Extension Phone # : ___________________ Pager # : ____________

STATEMENT OF RESPONSIBILITY: My signature below indicates that I am responsible for observing all Library policies and procedures. I further understand that I will be charged the Library’s acquisition costs and a processing fee for replacement of missing items, or a late fee for Library items which are not returned on time.
Penn State students: I authorize Penn State to charge my Student account for any library fees that occur.
SIGNATURE __________________________________________ Date: __________

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If you are not from Hershey, PSU CAMPUS _______________________

PRIMARY - LOCAL Address: (Students, External, Summer program)

___________________________________________________________________________
Street / Apt.

_________________________________________________________________________________
City State Zip Code

HOME PHONE: _______- ______- _________________