Date: * 

First Name: *  

Last Name: *  

Address (Street/Apt.): * 

City, State, Zip Code: *  

Home Telephone: * (with area code)  

Other Telephone:  (with area code)      Work Cell phone Pager Other

MCC ID #: *  (Please enter your assigned Banner M number which
serves as your MCC ID #)

MCC Student E-mail Address: *  (For example:  jdoe001@student.monroecc.edu)

For information on your MCC Student E-mail Account, visit the MCC Students home page and click on the "Find your Account" or "Common Questions" links in the Email Help drop down menu at the top left corner of the page.

List Distance Learning Course Name(s), Number(s) and Section(s) enrolled in: *

(For example: Basic Consumer Nutrition: SLN BIO-117-SL1)

Are you working towards a degree ?   Yes No

If yes, please give anticipated date of completion:  

Comments:

I authorize the staff of MCC Libraries to check out materials to me upon my request.

• I agree to accept responsibility for those materials which are checked out and sent to me.

• I understand that responsibility extends from the time the materials are shipped until they are once again received by MCC Libraries.

• This authorization will be in effect for the current academic semester.

Thank you!