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registration form - County of Henrico Public Library

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					                              County of Henrico Public Library
                                    Member Registration Form


                                               Please print

Name _______________________,________________________________ Adult _____ Juvenile _____
       Last       Jr., Sr., III First           Middle                        (under 18)

_________-________-___________                 _____________________              Male /Female (circle one)
Adult /Co-signer’s SSN or DMV ID                  Birthdate (mm/dd/yyyy)


Residence address (Required):                               Mailing Address (if different):

__________________________________________                  _______________________________________
Street                          Apt.                         Street/PO Box

__________________________________________                   _______________________________________
City               State       Zip                            City               State       Zip


City/County of Residence ________________________________________________________________

_______________________                    _____________________________________________________
Phone (local number only)                          Email Address (If case sensitive, please specify)

I would like to be notified for available holds by: ___ EMAIL ___ PHONE (check one)
_____________________________________________________________________________________

Registrants are required to provide a valid DMV ID or a picture ID. If current address is not printed on any of these,
then one of the following forms of residence verification is also required: bank statement, cancelled mail within 30
days with name and address, imprinted check, rental agreement, utility bill.

Please read before signing:

The undersigned adult is responsible for materials borrowed, fines charged, and any damage, whether
intentional or unintentional, to library property including public-use computers or any related software or
hardware provided by the library. Overdue materials on a juvenile’s card may affect the status of the
adult’s card and the card of other juveniles for which the adult has cosigned.

_______________________________________                 _____________________________________
Registrant’s signature                                  Parent/Legal Guardian Signature


_______________________________________                 _____________________________________
Date                                                     Print Parent/Legal Guardian Name



                                         LIBRARY USE ONLY

         ID #__ __ __ __ __-__ __ __ __ __-__ __ __ __           Staff _____ Reg Checked ____

           Non-resident ____ Reciprocal _____ Temp Card _____ New Resident _____

                   User Cat 2: ______________________________


Revised May 2009