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Adult Library Card Application

Please fill out the application completely. The information submitted is only used for library services.
Last Name:
First Name:
Full Middle:
Gender:	Male Female
Mailing Address:
City:
County:
Zip Code:	State:
Street Address: (if different from above)
Home Phone:	(000) 000-0000
Work Phone:	(000) 000-0000
Date of Birth:	MM: DD: YYYY:
If you would like to receive e-mail notification of holds and overdue items, please enter your
E-mail:
By submitting this form I accept responsibility for all materials borrowed and/or all costs incurred. I will report theft or loss of the card or change of address to the library immediately. I understand that this card can be revoked at any time. Information submitted on this form is secure using the SSL protocol (Secure Sockets Layer).