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Library Media Specialist Form

By completing and signing this form I confirm my participation in the UConn Early College Experience Program, certify that all personal information provided is accurate and will be used to create and/or maintain my University records, and consent to comply with the policies and procedures of the University of Connecticut.

Once this form is submitted we will contact you for your social security number so a University account can be created or reactivated for you. Access can then be granted to UConn’s Library resources. Providing your social security number is voluntary; it is not required. If you choose not to provide your social security number, you must disclose if you have previously been affiliated with the University.

Library Media Specialist Form

Are you a:*
- New Library Media Specialist
- Current Library Media Specialist (updating information)
School Information
High School Name*
High School Address*
Street Address Address Line 2 City State ZIP Code
High School Phone Number*
Phone extension
High School Fax Number
High School Email Address*
Personal Information
Prefix*
- Dr.
- Mr.
- Mrs.
- Ms.
First Name*
Middle Name*

This information is used to search the University system to connect any past records that you may have. If not applicable, please indicate "N/A"
Last Name*
Suffix
Maiden or Previous Name*

This information is used to search the University system to connect any past records that you may have. If not applicable, please indicate "N/A"
Date of Birth*
MM slash DD slash YYYY
Position/ Title
Personal Home Address*
Street Address Address Line 2 City State ZIP Code
Personal Phone number
Personal Email Address (optional)
I understand that I will be contacted to provide my social security number.*
- Acknowledge
We request social security numbers so that our Library Media Specialists can gain access to the UConn Libraries’ online research materials. Providing your social security number is voluntary; it is not required. Unfortunately, if you choose not to provide your social security number, you will not have access to the library. *The University requests that you provide your Social Security Number (SSN). We are required by federal law to inform you of this request. The SSN is collected to enable the University to comply with federal requirements mandated under IRS tax laws and the Title IV student aid legislation and for other administrative purposes. The University assigns each library media specialist a unique identifier that is not the SSN that is used for most administrative purposes.
Site Rep /S/ Signature
Email
This field is for validation purposes and should be left unchanged.