Application for Library Membership
ABN 63 942 912 684

Fields marked * are compulsory

 
Title (Mr,Mrs,Ms,Dr,etc.)

Last Name*

First Name and other initials*

Date of Birth*
As required by the Broadcasting Services Act

Departmental Address*

Home Address*

Email Address*

Phone No. *  
Home and/or
Work and/or
Mobile

 Retired UQ Staff   Position
  Years of service
  Staff number
 UQ Senator     
 Other
e.g. Visiting academic or scholar		   Institution
Are you both staff and student at UQ?     Yes     No
I agree to abide by the Library conditions of use as stated on the Library's website.
Signature _________________________ Date _________________
Library Use Only
Date Received  
Expiry Date
Barcode 24067
Patron type  
Stat class