Fines and disputes form

Request for library fines to be waived/Book dispute

Part 1 My details

Name                      ....................................................................................

Library number ............................................................................................

Email Address           ....................................................................................

                             ....................................................................................

If you can’t be contacted by email please supply a postal address.

Telephone No: .......................................                  Date............................

I am (please tick):

I am being fined or am in dispute over these books:

Please fill in the details or provide a printout. Continue on the back if necessary.

I am asking you to waive my fines for (please tick):

These lasted from            /    /             to       /    /  

Part 2 Confidentiality

All discussions at the Base and within the Fines and Disputes Team are confidential.

If you prefer not to discuss this at the Base, please put your form into a sealed envelope for the attention of the Customer Service Development Manager or the Resource Circulation Manager.

Part 3 Papers

Please fill in this part if you are attaching papers to support your request.

I am attaching the following documentation (please tick):

If you have to give these papers to someone else as part of a special factors appeal, we will accept photocopies.

I have enclosed a statement from:

Name:                    ....................................................................................

Division/School:        ....................................................................................

Contact number:      ....................................................................................

who is supporting my case.

Please tell us why you think we should waive your fines or why you want to dispute a book on your library record.

Part 5 Appeal against the decision on my previous form

Please give us the form within 28 days of the decision on your first form.

I am not happy with your decision on my first Library Form for Fines & Disputes, and would like you to review it. I would like to add this information.

Part 6 Declaration

The information I have given on this form is true and has meant I could not return my books on time/I dispute a book on my library record.

Signed: ................................................................Date: .............................

Part 7 For our use