Library Card Application

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Township

County

Access library account online?

yes

no

I will be responsible for all materials checked out on this card. I will notify the Library if my card is lost/stolen or if I change my address or phone #. I will comply with library rules/policies. I understand there will be charges for lost, damaged, stolen materials.

Signature for card holder under 16

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Permission for:

Internet

DVDs

Restricted DVD

Signature

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