AHEC Digital Library Membership Application
Moses Cone Health System
Please complete and return this form to your Greensboro AHEC ADL Administrator who will contact you with your user name, password, and any other information you might need for accessing the electronic resources available through the AHEC Digital Library.
I understand that my AHEC username and password will be confidential and not transferable to others. Through the Digital Library I will have access to currently available cost-effective web resources, including those for medical literature searching. Any questions about resource access should be directed to my AHEC Library or to the AHEC ADL Administrator.
My signature indicates an understanding of the confidentiality issue and of the potential access limitations.
Signature:
Date:
Please print the information below.
First Name Last Name _____________________________
Title__________________________________ Degree_________ Department:_________________________
Location/ Campus: _____________________________________________________________________
Address__________________________________________________
City_____________________________ State____ Zip Code______________________
Phone__________________ Extension_______________________
Fax ____________________________ Email __________________________________________
Please specify profession: ___ Physician ____Nurse ___Dentistry ___Mental Health ___Pharmacist ___Allied Health
Other: _______________________________________________
Are you a Preceptor or do you have a Clinical Appointment?_____Yes _____No
If yes, for which school? _________________________
Please mail or fax registration form to:
ADL Administrator Phone: 832-8025
Greensboro AHEC Fax: 832-7591
1200 North Elm Street
Greensboro, NC 27401