Form Dhcs 5018 - California Staff Loan Agreement - Health And Human Services Agency
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1State of California—Health and Human Services Agency
Department of Health Care Services
Program Services Division – Resource Center
MS 2601
PO Box 997413
Sacramento, CA 95899-7413
Department of Alcohol & Drug Programs
Resource Center Lending Services
Staff Loan Agreement
Please print, fill out completely and return to the Resource Center Lending Services.
Name: ______________________________________________________________________
Last
First
Middle Initial
Supervisor: _________________________________________________________________
Last
First
Middle Initial
Division Name: ______________________________________________________________
Cubicle Number: ____________________________
Telephone Number: (____) _______________________ Fax: (____) ____________________
E-mail Address: ______________________________________________________________
Please Read and Sign:
I agree to abide by the Lending Services rules & policies, to pay all charges for any lost or damaged library
materials accumulated on this card and to notify the Resource Center of any change of employment or loss of
card. I understand I am responsible for all materials checked out on this card. Should I fail to return materials
and/or promptly pay any charges incurred, I understand my loaning privileges will be suspended and my wages
may be garnished for the replacement cost of the materials.
__________________________________ ___________________________ __________
Signature of Applicant
Job Title
Date
__________________________________ ___________________________ __________
Signature of Supervisor
Job Title
Date
For RC Lending Use Only!
Patron Number Issued:__________
Requestor Type:________________
Date:________________________
Issued by: _____________________
DHCS 5018 (06/13)
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