Rural Clinical School Hospital Staff Application for Library Membership
ABN 63 942 912 684
Fill out sections required, print and sign the form. Fields marked * are compulsory
Employment details
Staff ID number
Position
(eg. RN, Intern, OT, Admin Officer, etc.)
Are you also a University of Queensland Staff Member or student?
Yes
No
Employment status
(please tick all that are applicable)
Casual
Fulltime
Part Time
Contract
Contract expiry date
(if applicable)
Personal details
Title
(eg. Mr,Mrs,Ms,Dr,Sr,A/Prof,Prof etc.)
Last Name
*
First Name and other initials
*
Hospital Address
*
(Include hospital or off site address or building location
eg. Dept. of Medicine, Rockhampton Hospital, 4700)
Home Address
*
Date of Birth
*
As required by the Broadcasting Services Act
Email Address
*
Phone No.
*
Work
Home
Mobile
Pager
I agree to abide by the
Library Code of Practice
as stated on the Library's website.
I have read the
RCS Hospital Staff membership guide
and I am aware that membership does not include remote access to electronic resources.
Signature
_________________________
Date
_________________
Hand the form in at your Branch Library. You must also show your hospital ID.
Library use only
Date received
Expiry date
Barcode
24067
Patron type
Stat class
