Amount of charge $____________________ 

Name as it appears on the card____________________

Card number__________________________

Expiration date _____/_____(mm/yy)

___________________________________
Account Name
(this should be a unique name to the group)

_________________/_________________
Contact Person / Telephone # or e-mail
(to whom account information will be directed)

___________________________________
Department, School, or ORU

___________________________________
Campus Address

___________________________________
Account Principal
(faculty or administrator responsible
for account balance)

_________________/_________________
Office Phone / Message Phone or e-mail

Authorized Users: (Everyone, other than proxies, who will have actual possession of library materials must be on this list and must have his/her own library card.)

Name              Status*               Address             Phone/e-mail             Signature**           Date
                            (F, S, G, P)

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

(List additional names on a separate page and attach to this form.)

* Status:     F = Faculty     S = Staff     G = Grad     P = PhD Candidate 

** I hereby authorize the BAKER Service to act as my proxy borrower in the Library at UC Berkeley. I agree to use BAKER only for my own research needs, and in compliance with the Library rules and policies. When requesting photocopies, I accept full responsibility for compliance with the copyright law of the United States (Title 17 U.S. Code).