Library Card Registration Form by JwbDrK8

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									Lewis & Clark Library Card Application
                    Proof of Current Residence Required
Name_________________________________________________________________                                    Today’s Date________________
Birth Date______________________________________________________________                                   Female                Male
Mailing Address_________________________________________________________
   City State Zip_________________________________________________________                                         Location of Residence
                                                                                                                         (circle one)
Residential Address______________________________________________________
                                                                                                          Helena City Limits
   City State Zip_________________________________________________________                                East Helena City Limits
Primary Phone______________________ Secondary Phone_____________________                                  North of Helena
                                                                                                          East of Helena
                                                                                                          West of Helena
            Check here to receive Library notices by email only.                                          Augusta
                                                                                                          Lincoln
Email Address___________________________________________________________                                  Lewis & Clark Other
                                                                                                          Outside Lewis & Clark County
I agree to comply with the policies of the Lewis & Clark Library. I agree to present my card for
checkouts. I agree to report immediately if my card is lost or stolen. I agree to report change of
contact information. As a card holder or guardian, I take full responsibility for all materials                      Library Use Only
checked out on this card. I understand that Library privileges can be suspended if abused.                Old Card Number
                                                                                                          ____________________________________
                                                                                                          Reason Stopped
Signature_______________________________________________________________
                                                                                                          _____________________________________
                                                                                                          Paid$________________________________
I understand that children have access to all materials in the Library and I accept responsibility for
                                                                                                          Expiration
 monitoring my child's access to print, media and electronic formats including the Internet.
                                                                                                          _____________________________________
                                                                                                          Initials
Parent/Legal Guardian____________________________________________________                                 _____________________________________

								
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