USC Dental School

Faculty & Staff Registration Form

(Subject to verification)

* Required information

* E-mail address :

* Last Name : * First Name : Initial:

* Social Security Number :

* Full-Time Part-Time Volunteer Other

Address 1 (Office / Dental School Address / Health Sciences Campus Address):

* Dental School Dept. or Program Name : * Building & Room Number :

* Mail Code : * Office Ext. : Private Practice No. :

Address 2 (Business / Private Practice Mailing Address):

Number and Street Name : Suite No. :

City and State : Zip Code :

Business Phone Number : Beeper / Pager Phone Number :

Address 3 (Current Home Local Mailing Address):

* Number and Street Name : Apartment / Condo / Suite No. :

* City and State : * Zip Code :

* Home Phone Number :

Use of your library card signifies agreement to comply with all University of Southern California and Health Sciences Libraries regulations and policies. This library card is non-transferable and you are responsible for all use made of this card. I understand I must present University ID at the Wilson Dental Library to activate this application.

* I agree. Yes