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Visiting Library Service Application Form

First Name:

Last Name:

Address:

City:

Postal Code:

Type of Dwelling Type of Dwelling

House

Apartment

Other

Phone Number:

Date of Birth (mm/dd/yyyy)

Email Address:

Alternate Contact Person

The following family member or friend may act on my behalf:

Alternate Contact Name (first and last):

Alternate Contact Email Address:

Alternate Contact Phone Number:

Material Types (Please check all that apply): Material Types (Please check all that apply):

Regular Print

Large Print

Paperbacks

Magazines

Books on CD

Playaways

DAISY Audiobooks

DVDs

Music

CDs

We keep a record of your reading preferences and the library materials you have borrowed in order to provide better service to you. This list and your personal information are kept confidential and are not shared.

Do we have your permission to keep this information on file and in our computers? Do we have your permission to keep this information on file and in our computers?

Yes

No

I agree to be responsible for any loss or damage of library materials delivered to me. I understand that fees will be charged for any lost or damaged material.

Yes

No

Additional Comments

Contact(s)

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