Department：

Your full name：

Telephone：

Conference title：                                       

Member number：

From     o'clock to      o'clock  on      /     /     (month / day / year)

Course number：                                          
Subject number：

Authentication：NCKU Medical College Academic Affairs___________________________

＜Medical Library replication below＞  

□Yes                      □No

Reason：   

Authentication：Medical Library

□ Charge：＿＿＿＿＿＿NT dollars    Receipt number(收據編號)：_____________
□ free of charge                          

Handler：______________

Date：      /     /     (month / day / year)

The explanation of charge way：(According to NCKU Medical Library Committee on May,27,2004)：

1. Free of charge: First, the curriculum need to be authenticate by NCKU Medical College Academic Affairs which give formal curriculum number and subject number. Second, the curriculum do not charge for students or trainee.   
2. Charge: 5 thousand for 4 hours in Computer Room.

P.S.：

1. Requested date/time be must in opening hour of Medical Library.
2. Computer Room Application Form is only disposed in circulation desk. Please do not E-mail this form.
3. If you have any question, please ask a librarian at ext. 5159.