If you are under the age of 18, your parent or legal guardian must fill out and sign

the application.

Please Print Last Name: First Name: Age Group:

(Check One)

Middle Name: 0-5 yrs Male 6-11 yrs 12-18 yrs Female 18 and Older

Gender: Street Address: City: Email Address: Home Phone: (

State: @ ) Mobile Phone: By Text

Qwest Sprint PCS T-Mobile

Zip:

(Check One or Both)

When we need to contact you for holds or overdues, how do you prefer to be contacted?

By Email
Alltel AT&T Boost Mobile Cingular Corr Wireless Cricket Wireless Nextel

If you wish to be contacted by text please check your Mobile Service Provider

TracFoneUS Cellular Verizon Virgin Mobile USA

Drivers License Number (If 15 or older): Parent/Guardian (if under 18):

May not live in the same household!

Reference Name: Reference Address: Reference Phone Number : Birth Date: / / ( ) In order to access E-Books and OPAC from home you will need a pin #

Pin Number: The person whose signature appears below or his/her parent/guardian is responsible for all materials borrowed on this card, including any borrowed before it is reported lost or stolen. Report loss or theft of my card promptly I agree to: Pay all fines or fees Abide by the policies of the library Report change of name or address promptly

Signature

Date:

I authorize and assume responsibility for my minor child to borrow any library materials and access to the Patron Computers:

Signature, Parent/Guardian

Date:

LIBRARY USE ONLY: Card #______________/New Registration Re-Registration Lost Card/ Initials___________