LIBRARY CARD APPLICATION / UPDATE FORM
Todays Date ________/________/_____________ Birth Date ________/________/______________
MM DD YYYY
Note: Those applying for a Child Only or Teen Only card need to fill out the first six lines; phone and email are optional. Internet Only card applicants need to fill out the first six lines and sign the borrowers agreement on the back. Please Print Clearly
Name _________________________________________________
First
MI
________
_________________________________________
Last
Mailing Address ______________________________________________________________________________ ______________
Street or P.O. Box Apt
_________________________________________________________
City
_________
State
__________ ___________
ZIP
__________________________________________________________________
County
Phone (_________) _________-______________
Street Address if different from above or Address of Parent/ Legal Guardian if different from above
Street
______________________________________________________________________________ __________________
Apt
_________________________________________________________
City
___________
State
____________- ____________
ZIP
Phone (_________) _________-______________
E-mail _________________________________________________
How do you want to receive information about this account? If you sign up for email or text message, you will also receive courtesy notices before items are due, before your library card expires, and before your card is blocked due to an unresolved missing item. (check one) Phone E-mail _____________________________________________ Text Message Cell Phone (_________) _________-______________ Cellular Service Provider_________________________
Please check here if you do not want to receive the Librarys monthly e-update. May we share your address, phone number, and e-mail address with the Librarys Foundation & Friends groups for fund-raising purposes? Yes No
Are you a teacher or educator applying for a Library card with educator status? Yes No School Name (If applicable) _________________________________________________________________ School Phone (_________) _________-______________ Your e-mail at School______________________________________________________________________ The Library will use the personal information you provide for official purposes only. We do not sell our list of account holders to other organizations or groups.
BORROWERS AGREEMENT
Read Before Signing!
I agree: G To be responsible for all materials borrowed with my card. G To pay all fines and fees associated with my card. G To report the loss, theft, or abuse of my card immediately. I understand that I am responsible for all fines and fees and any items checked out on my card prior to being reported lost or stolen. G To report changes in my account information. G This is my only Library card from the Public Library of Cincinnati & Hamilton County. Providing false information in this application is a felony of the third degree punishable by up to five years in prison and a fine of up to $10,000. ORC 2913.42. Your Signature: X _____________________________________________________________ Date_______________________
PARENT/GUARDIAN AGREEMENT
Select the profile for this borrower (required): _______ Unlimited Access: Borrower will be able to check out all circulating materials, including all videocassettes and DVDs. _______ LimitedNo Videos: Borrower will be able to check out all circulating materials except videocassettes and DVDs _______ Limited-Juvenile: Borrower will be limited to checking out materials cataloged for children. As a parent or legal guardian of this borrower under the age of eighteen, I agree: G To be responsible for this borrowers selection and use of library materials. G To pay all fines and fees associated with this card. G To report the loss, theft, or abuse of this card immediately. I understand that I am responsible for all fines and fees and any items checked out on this card prior to being reported lost or stolen. G To report changes in this accounts information. Applicants under the age of 18 will be required to complete a new library card application upon turning 18. Providing false information in this application is a felony of the third degree punishable by up to five years in prison and a fine of up to $10,000. ORC 2913.42. Name and Signature of Parent/Guardian: (Please Print) _______________________________________ ______________________________________ _______ (Last) (First) (MI)
(Please Sign) X_________________________________________________________________ Date_________________
FOR OFFICE USE
___New Application ___Child Only Did You Verify: _____Address? _____Educator Status? _____Photo ID? (18+) _____Age/Card Profile? _____Reciprocal Library Card? ___Update ___Internet Only ___Downloadable Only ___Teen Only
LIBRARY CARD NUMBER
affix bar code or write number here
Form no. 00360 Revised 08/2011
Staff Name ________________________
Location______________
