PLEASE PRINT Title: (circle one) Mr. Miss Mrs. Ms. Dr. Gender: (circle one) M F Not Applicable Last Name First Name Middle Initial
_________________________________ ___________________ _________________
Street Address Apt. Number City State Zip Code Plus 4
___________________________ _______ ________-________ ______ / _____ / _____
Date of Birth_____________________________
Preferred Mailing Address & Zip Code __________________________________________________________
Municipality (Township or Borough) _____________________ County _________________________
Workplace or School Name Work or School Address & Zip Code
______________________________ __________________________________________________________
( _____ ) _____ - ___________ ( ____ ) _____ - ___________ X ___ ( ____ ) _____ - _______
Home Telephone Work Telephone Cell Phone
______________________@_________________________________ ( ____ ) _____ - _______
Email Address Fax Number
____________________ Driver's License #
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REMEMBER TO REQUEST YOUR PASSWORD FOR HOME ACCESS TO YOUR LIBRARY ACCOUNT!LIBRARY CONFIDENTIALITY:
In accordance with the Pennsylvania Library Confidentiality law please note thatinformation about items borrowed or requested may only be revealed to the library cardholder. [PA. Title 24; Ch. 16 - Article IV;24 P.S. § 4428 Library Circulation Records. Request a copy from the librarian or view at http://www.mclinc.org/RequestForRecords.htm]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 _________________________________________________________________________________________
Please Print Parent/Guardian Name __________________________________________________________________________________
Parent/Guardian Address (If different from above) _______________________________________________________________________
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 ____________________________________________________________________________
FOR OFFICE USE ONLY
Former Patron ID: ________________________________ Home Library: __________________________________________
Registered At: ________________________ Date: ____/____/____ Term: ________________ Expiration Date: ____/____/____
Statistical Class: _______________ Barcode: ______________________________ Patron Code: __________________
Eligible for Access [ ] Yes [ ] No Proof of Residence: _____________________________________________________
Registration Taken By (initials): _____________________ Date Entered: ___/___/___ By (initials): _____________________