Library Card Application Form

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MC-NPL
A Member of MCLINC
LIBRARY CARD APPLICATION
Title
: __
Gender
: __
Mr. __ Miss __ Mrs. __ Ms. __ Dr.
Male __Female
(check one)
(check one)
Name __________________________
________
___________________________________
First Name
Middle Initial
Last Name
Street Address _____________________________________________
Apt # _____________
City ___________________________
State ______
Zip Code +4
__________________
___________________________________________________________________________________
Preferred Mailing Address & Zip Code
(if you use a P.O. Box or alternate address to receive mail)
Phone ________________________
Cell Phone
_________________________________________
Number/Carrier
Email ______________________________________________________________________________
Used to send reminders when library items are coming due and to send the first overdue notice.
Preferred Method for Notices (check)
Email
Phone
Cell Phone AND
Additional Text Message
………………………………………………………………………………………………..
I would like to receive program information by email.
I would like an e-receipt at check out.
YES
NO
YES
NO
Driver’s License Number:
Date of Birth _______________
__________________
(mm/dd/yyyy)
Municipality
__________________________________
______________________________
Township or Borough
County
Workplace / School Name: ____________________
Bookmobile Stop (if applicable)_______________
Please Read and Sign
I hereby apply to use the library and promise to obey all its rules. I accept full responsibility for all materials
checked out on this card and for all charges associated with its use. I agree to pay promptly all fines and
damages charged to me, and to give prompt notice of any change in my address or loss/theft of my card.
Your signature:
_____________________________________________________
Children under the age of 18
Children under the age of 18 must have the signature of a parent or guardian. As parent or guardian of the child named
above, I give permission for him/her to borrow materials from the library. I agree to pay all fines and damages charged to
his/her card, to be responsible for supervising his/her selection of materials and to make sure he/she obeys library rules. I
understand that children’s cards are subject to the confidentiality law cited above.
Parent/Guardian Signature
__________________________________________________
Parent/Guardian Name (Please print)
____________________________________________
Parent/Guardian Address (If different from above)
______________________________________
FOR LIBRARY USE ONLY
Former Patron ID: ______________________
Home Library: ____________________________________
Registered at: ________________ Date: ___/____/____ Statistical Class: _______
Patron Code:_____________________
Eligible for Access: [ ] Yes [ ] NO Proof of residence / ID: ____________________ Registration Taken By (initials): ____________
Date Entered: ___/___/______ By (initials): __________
BARCODE ISSUED: ______________________
Term: ___________
Expiration Date: ___/___/_____
:
LIBRARY CONFIDENTIALITY
In accordance with the Pennsylvania Library Confidentiality law please note that information
about items borrowed or requested may only be revealed to the library cardholder. [PA. Title 24; Ch. 16 - Article IV; 24 P.S. section
4428 Library Circulation Records] View the entire privacy policy at

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