Appeals Form

Appeal # ______

Circulation Desk
UW Oshkosh Polk Library
800 Algoma Blvd.
Oshkosh, WI 54901
(920) 424-7314
FAX (920)-424-2175

Form Instructions:

1. Fill out this form completely, print it and hand in or mail to the University of Wisconsin Oshkosh Polk Library-Circulation/Reserve Staff. You are encouraged to provide documentation to support your appeal.
2. You must see/call the staff for the time and location of the next meeting, rescheduling, or any other information. Please do not hesitate to ask any questions or call (920) 424-7314 regarding this matter.

   Name (print):

   Patron Signature:

   Campus ID number or barcode:

   Email Address:

   Current Address:

   City:

   State:
   
   Zip:

   Phone (with answering machine):

   Do you wish to appear before the appeals committee ? (Attendance is Optional)

   Yes No

Statement of facts related to your appeal: (additional pages accepted)
Please include the title(s) of the material you are appealing.

Access Services Staff Processing:

1. Check form to verify that it is complete
2. Date Received and Initials: _______________
3. Enter necessary information in Appeals Log and place form on designated appeal staff's desk.

Committee Action: Approved : ______ Denied: ______ Other: ________________________
__________________________________________________________________________

Signature of Committee Member: _______________________ Date: ________________