I hereby request that this student indicated below be given a "Proxy Borrower Barcode".  I understand that the person indicated below will be able to check out material at the library, using this barcode, under my account.  I further understand that I am responsible for the material being returned to the library, as if I personally had checked out the material.  I authorize the person indicated below to have Proxy Borrower Privileges to my account at the library within the time frame indicated below.