Proxy Representative Request December 17, 2020 Webform To request that a Proxy Representative be granted access to your room to retrieve an item, please: Read and familiarize yourself with the Proxy Representative policy in the Guide to Living Complete and submit this form. Student Information Name UNI Email Building - Select -47 Claremont Ave548 West 113th Street (brownstone)600 West 113th Street627 West 115th Street (brownstone)Broadway HallCarlton ArmCarman HallEast CampusFSLFurnald HallHarmony HallHartley HallHogan HallJohn Jay HallMcBain HallRiver HallRuggles HallSchapiro HallSICWallach HallWatt HallWien HallWoodBridge Hall FSL Building - Select -Alpha Chi Omega: 536 West 114th StreetDelta Gamma: 552 West 113th StreetKappa Alpha Theta: 534 West 114th StreetKappa Delta Rho: 548 West 114th StreetSigma Chi: 523 West 113th StreetSigma Delta Tau: 540 West 114th StreetSigma Phi Epsilon: 550 West 113th StreetSigma Nu: 556 West 113th Street554 West 114th Street SIC Building - Select -542 West 114th Street546 West 114th Street552 West 114th Street554 West 114th Street 1st Floor604 West 114th Street606 West 114th Street619 West 113th Street Room Number Proxy Representative Information Please note the following: The Proxy Representative must present a form of ID prior to access. The time and date of access is subject to approval by Housing. Housing may request an alternate date or time. Proxy's Name Proxy's UNI: Requested Date and Time for Proxy Access Requested Date and Time for Proxy Access: Date Requested Date and Time for Proxy Access: Time Description of item(s) being retrieved by proxy: By checking this box, you consent to Columbia Housing providing this Proxy Representative access to your room and/or suite. You acknowledge that Columbia Housing did not recommend or select the proxy and does not provide supervision or management of the proxy’s activities in your room and/or suite. Columbia University is not liable for any lost or damaged property. Submit