Charlotte AHEC

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AHEC Library & Information Resource Center

AHEC Library & Information Resource Center

ADL Request Form

Note: If you are on staff at a participating hospital, you are eligible for a free membership. If you are not on staff at any of these hospitals, you may purchase an individual membership; prices available upon request.

Contact Information

First Name:	Last Name:
Email: CHS Other CHS Information Email: Phone: Other Information Email: Phone: Location/Unit: Supervisor:
Fax:
Occupation: Administrator Allied Health Professional Dentist Medical Technologist/Clinical Laboratory Scientist Nurse Occupational Therapist Physical Therapist Physician Physician Assistant Pharmacist Student
Hospital Affiliation: Anson Community Hospital Carolinas Medical Center Carolinas Medical Center-Mercy Carolinas Medical Center-Pineville Carolinas Medical Center-University Cleveland Regional Medical Center Gaston Memorial Hospital Kings Mountain Hospital Lincoln Medical Center Northeast Medical Center Stanly Memorial Hospital Presbyterian Hospital (Novant) Union Regional Medical Center Other
Are you a Preceptor? Yes No If yes, please list students' home institutions:

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