Faculty Proxy Request Form

To receive an email reply to your question, please include your email address below. An asterisk (*) indicates a required field.
Date:*
Faculty name:*
Faculty email address:*
Faculty Extension:*
Department:*
Name of Person(s) authorized to checkout:*
Duration of this Proxy:*
This proxy will expire at the end of the time period you choose. If you wish to extend the authorization for the person/persons listed in this request, a new proxy authorization must be submitted .
If Other - Explain
Additional Comments