Library Card Application

October 25, 2018

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New Member Certification * Required
- I understand and hearby certify I am a new applicant requesting a membership.
I understand this form is an application for new memberships only, for an expired membership or replacement card I will have to visit the Library in person.

Name * Required
First Last
Birth Date: - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone: * Required
Secondary Phone:
Email

Do you have any minor children (between the ages of 12 and 18) who may have their own library card with you as their grantor? * Required
- Yes
- No

Authorized Users:
List anyone below whom you authorize to use your card without your presence. List their name, birth date and whether or not they may use the internet and check out movies (in that order). (to check out movies they must be at least 18)Example - John Doe, 00/00/0000, Yes (or no), Yes (or no)

Use Agreement: * Required
- I agree with the Use Agreement.
I understand that the library will issue one card to me free of charge and that I must have that card with me when I come to the library to use any services. If I lose or misplace that card, I will be charged a replacement card fee of $5 and must pay the fee in order to be able to continue to use the library services. Additionally, I agree to accept the library's policies concerning borrowed materials and agree to return any materials I borrow in a timely fashion. Failure to do so could cause a suspension of my library privileges. I also acknowledge that I will be charged replacement costs plus administrative fees for any items that I fail to return for longer than 30 days past their due date--even if those items are returned to the library after that time--and that all my library privileges will be suspended until the account has been settled.
Movie Checkout Policy * Required
- I have read and agree to the following movie policy. I also agree I am over the age of 18 and am responsible for any materials borrowed on my account.
1. Movies (DVDs) may only be checked out by patrons over the age of 18 years. No children or minors will be allowed to checkout videos. No exceptions. 2. Only 2 movies may be checked out per household at any one time. 3. Only 2 movies may be checked out per day. A patron may NOT check out movies and return them and check out more in the same date. 4. Movie check outs are for a 7 day period only. Renewals are not permitted. 5. If a movie is lost or damaged, the patron will be charged a minimum fee of $25 to replace the movie. If a movie case is damaged or destroyed, the patron will be charged a processing fee of $5 to replace the damaged movie case. 6. If a patron is consistently late returning movies, the librarian can suspend a patrons account so that no movies can be checked out or reduce the number of checkouts from 2 to 1 at a time. Per library policy, any item more than 30 days past due will result in a patron's account being charged replacement charges for that item--even if the item is returned after the 30 days past due period. Continued late returns can results in permanent suspension of the library account. 7. Defensive Driving videos are also available to be checked out. If these are lost or damaged or a patron fails to return them to the library, the patron will be required to pay a minimum fee of $50 to replace these DVDs.
Electronic Signature: * Required
First Last
I agree to and understand all terms stated above. I understand this field will serve the same purpose and carry the same weight as a written signature.
Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Driver's License/ID * Required

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Library Card Application

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