Greensboro AHEC

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:                                                          

Michael Willet                                       Phone:  832-8213 
Greensboro AHEC                                Fax: 832-7591 
1200 North Elm Street
Greensboro, NC 27401