LIBRARY CARD RegIstRAtIon

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LIBRARY CARD RegIstRAtIon Individual responsible for fines and fees must complete this form. Please print in blue or black ink. Name____________________________________ __________________ Birthdate_______________. First Name Middle Last MM/DD/YYYY. Mailing Address_________________________________ ___________________________________. Street Address/Apt # City State Zip Physical Address_________________________________ ___________________________________. Street Address/Apt # City State Zip Primary Phone____________________________ Alternate Phone_____________________________. Email Address_____________________________ Alternate Email_____________________________. (for notices and LIBRARY information). FOR YOUTH BORROWERS UNDER 18 YEARS OLD: Youth Verification: o school, government oR social services agency ID o birth certificate o immunization record o IN PERSON.

LIBRARY CARD RegIstRAtIon Individual responsible for fines and fees must complete this form. Please print in blue or black ink. Name_____ Birthdate _____