Please complete all information. Your Proxy will NOT be permitted to borrow or request items if this form is incomplete. Faculty Name Faculty G# Department Mason Email I authorize the designated proxy to borrow library materials on my behalf THROUGH JUNE 30 of the current academic year. If SHORTER TIME PERIOD is required, please state Expiration Date: Proxy Name Proxy G# My proxy has my permission (check the appropriate box to APPROVE) : To borrow Books and/or Media from Mason Libraries To pick up Books and/or Media requested through Washington Research Library Consortium (WRLC) Loan Service My proxy has my permission (check the appropriate box to APPROVE) : To pick up Books and/or Media requested through Document Delivery Service (also called Intercampus Lending) To pick up Books and/or Media requested through Interlibrary Loan (ILL) Service ACKNOWLEDGEMENT I understand I am responsible for all materials I understand I am responsible for all materials checked out in my name and any associated fines and/or fees for those items. I understand my library privileges may be suspended I understand my library privileges may be suspended for failure to comply with established George Mason University Libraries’ policies. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
