<form onsubmit="return checkLength()" name="ProxyForm" action="http://www.siue.edu/cgi-bin/FormMail.pl" id="ProxyForm" method="post">
<input name="recipient" type="hidden" value="cdugan@siue.edu,kgallac@siue.edu,mbigham@siue.edu" /><input name="subject" type="hidden" value="Proxy Form" /><input name="required" type="hidden" value="Name, IDNumber, Phone Number, email, Department, Term, Duration_of_Request, ProxyName, ProxyIDNumber" /><input name="redirect" type="hidden" value="http://www.siue.edu/lovejoylibrary/misc/thanks.shtml" />
<h3>Faculty/Staff Request to Authorize Proxy Borrower</h3>
<table border="0" summary="Online submission form for faculty to request a proxy borrower. " width="85%" cellspacing="3" cellpadding="3">
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<p align="left"><strong><span style="color:#ff0000;">For Faculty and Staff ONLY</span></strong></p>
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<td colspan="3"><strong>To request a proxy, read and complete ALL information below. <br /><br />Online proxy requests are processed M-F ONLY.</strong></td>
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<td width="47" colspan="2">
<p align="left"><strong>Faculty/Staff Name</strong></p>
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<td width="656" align="left">
<p align="left"><label for="Name"><input name="Name" size="45" type="text" value="" id="Name" /></label></p>
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<td width="47" colspan="2" align="right">
<p align="left"><strong>Faculty/Staff ID # 21811800</strong></p>
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<td width="656" align="left"><label for="IDNumber"><input name="IDNumber" size="20" maxlength="20" type="text" id="IDNumber" /></label></td>
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<td width="184"><strong>Phone</strong></td>
<td align="left" width="102"><label for="Phone_Number"><input name="Phone Number" size="20" maxlength="12" type="text" value="" id="Phone_Number" align="left" /></label></td>
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<td width="184"><strong>SIUE Email</strong></td>
<td align="left" width="102"><label for="email"><input name="email" size="20" maxlength="20" type="text" id="email" align="left" /></label></td>
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<table border="0">
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<th class="bigbodytitle" align="right">Department:</th>
<td class="bodytext" align="left"><label for="Department"><select name="Department" size="1" id="Department"><option selected="selected">ACCT</option> <option>AD</option> <option>ADED</option> <option>ANTH</option> <option>ART</option> <option>AS</option> <option>BIOL</option> <option>BSED</option> <option>CE</option> <option>CHEM</option> <option>CHIN</option> <option>CI</option> <option>CIS</option> <option>CIV</option> <option>CJ</option> <option>CMIS</option> <option>CNST</option> <option>CS</option> <option>DANC</option> <option>DS</option> <option>ECE</option> <option>ECON</option> <option>EDAD</option> <option>EDFD</option> <option>EDUC</option> <option>EE</option> <option>ENG</option> <option>ENSC</option> <option>ENVS</option> <option>EPFR</option> <option>ESCI</option> <option>FAC</option> <option>FIN</option> <option>FL</option> <option>FR</option> <option>GBA</option> <option>GEOG</option> <option>GER</option> <option>GRK</option> <option>GRN</option> <option>HE</option> <option>HED</option> <option>HIST</option> <option>HS</option> <option>HUM</option> <option>IE</option> <option>IME</option> <option>IS</option> <option>IT</option> <option>ITAL</option> <option>KIN</option> <option>LAT</option> <option>LIBS</option> <option>MATH</option> <option>MBA</option> <option>MC</option> <option>ME</option> <option>MGMT</option> <option>MKTG</option> <option>MS</option> <option>MSC</option> <option>MUS</option> <option>NURS</option> <option>OR</option> <option>PAPA</option> <option>PE</option> <option>PHAS</option> <option>PHEP</option> <option>PHIL</option> <option>PHPR</option> <option>PHPS</option> <option>PHYS</option> <option>POLS</option> <option>PROD</option> <option>PSYC</option> <option>RUSS</option> <option>SAB</option> <option>SCI</option> <option>SOC</option> <option>SOCW</option> <option>SPAN</option> <option>SPC</option> <option>SPE</option> <option>SPPA</option> <option>STAT</option> <option>THEA</option> <option>UNIV</option> <option>WMST</option> <option>OTHER</option></select></label></td>
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<th class="bigbodytitle" align="right">Select Term:</th>
<td class="bodytext" align="left"><label for="Term"><select name="Term" id="Term"><option>Fall 2011</option> <option>Spring 2012</option> <option>Summer 2012</option> </select></label></td>
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</tbody>
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<td valign="top" width="100" align="left">
<p><strong>Select duration of proxy:</strong></p>
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<td width="50"><label for="Duration_of_Request"><input name="Duration_of_Request" type="radio" value="One Transaction Only" id="Duration_of_Request" align="left" />One Transaction Only</label> <br /> <label for="Duration_of_Request"><input name="Duration_of_Request" type="radio" value="All" align="left" />All Term</label></td>
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<td colspan="2"></td>
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<p>A proxy borrower must be a valid SIUE student, staff, or faculty member in good standing (verified by Access Services).</p>
<p>After the proxy information is entered in the Library's circulation system, privileges will be in effect and the proxy will only need to provide their SIUE Cougar card to pick up materials for you. Proxy privileges are subject to all circulation policies and may be used for circulating items and interlibrary loan pickup only.</p>
<p><span style="color:#ff0000;">I hereby authorize the following person to borrow library materials on my behalf:</span></p>
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<td width="100" align="right">
<p align="left">Name</p>
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<td width="50" align="left"><label for="ProxyName"><input name="ProxyName" size="45" type="text" value="" align="left" id="ProxyName" /></label></td>
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<td width="50" align="right">
<p align="left">PROXY ID # 21811800</p>
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<td width="100" align="left"><label for="ProxyIDNumber"><input name="ProxyIDNumber" size="20" maxlength="20" type="text" align="left" id="ProxyIDNumber" /></label></td>
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<p align="left"><span style="color:#ff0000;">By submitting the proxy form, I understand that I assume full responsibility for items not returned and/or any fines or fees assessed for late return or damaged items.</span></p>
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<td>You will be notified by email when the proxy is established.</td>
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<td width="266" align="right"><label for="Reset"><input name="Reset" type="reset" value="Reset" id="Reset" /></label></td>
<td width="312"><label for="Submit"><input name="Submit" type="submit" value="Submit" id="Submit" /></label></td>
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</table>
</form>