Form Dhcs 5021 - California User Authorization Form - 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
California Department of Alcohol & Drug Programs
Resource Center Lending Services
1700 K Street, First Floor
Sacramento, CA 95811- 4037
(916) 324-5439 or (800) 879-2772
FAX: (196) 323-1270
User Authorization Form
Please print and fill out completely.
Organization/Agency/Division Name:________________________________________
Employee Name: _________________________________________________________
(Attach business card or letterhead stating position, with signature, to application)
Last
First
Middle Initial
Supervisor Name: _________________________________________________________
Last
First
Middle Initial
Agency Address: _________________________________________________________
Street Address
Suite/Cubicle #
City, State, Zip: __________________________________________________________
Agency Telephone Number: (____) ___________________Fax: (
) ____________
E-mail Address:__________________________________________________________
☐
Please place me on the RC e-mail and posting mailing lists to receive updated information.
Please Read and Sign.
I agree to abide by Lending Service’s rules & policies, to pay all charges for lost or
damaged materials accumulated on my authorized account and to notify Lending
Services of any changes uncured. I understand my loaning privileges can be suspended
and I also agree to be responsible for all costs of collections including Resource Center
staff attorney fees, if applicable. I further agree that all charges and costs may be entered
as a civil judgment against me and/or my organization.
________________________ ___________________________ __________
Employee Signature
Job Title
Date
________________________ ___________________________ __________
Supervisor Signature
Job Title
Date
For RC Lending Use Only!
Patron Number Issued:__________
Requestor Type:________________
Date:________________________
Issued by: _____________________
Mail in original with signatures.
DHCS 5021 (06/13)
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