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Last
Name ___________ First
Name ___________ Middle
Name ___________
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Drivers License
Number |
___________ |
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| Exp.
Date |
___________ |
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| Type |
___________ |
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| Occupation |
___________ |
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| If
Student…School |
___________ |
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| Grade |
___________ |
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Local Address: |
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| Street/Box |
___________ |
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| City |
___________ |
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| County |
___________ |
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| State |
__ |
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| Zip
Code +4 |
_____-____ |
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| Do
you reside within the city limits? |
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| Township |
___________ |
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| County
Commission District |
___________ |
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| Telephone
Number |
___________ |
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Permanent Address: |
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| Street/Box |
___________ |
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| City |
___________ |
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| State |
__ |
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| Zip
code +4 |
_____-____ |
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| Telephone
Number |
___________ |
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Work Address: |
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| Employer |
___________ |
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| Telephone
Number |
___________ |
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| Street/Box |
___________ |
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| City |
___________ |
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| State |
__ |
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| Zip
Code +4 |
_____-____ |
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The
link between your name and materials you’ve requested or borrowed is
private data. Other information
on this form may be classified as public data, and is subject to availability
in compliance with Minnesota laws and statutes. I promise to comply with all library rules,
to promptly pay fines or damages charged to me, and to give immediate
notice of change in my address.
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| Signature
( ink only) |
___________ |
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Date
of Birth
|
___________ |
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| If
use is under 15 years of age, please complete the following… |
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| Signature
of Parent or Guardian |
___________ |
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| Address
(if different from above) |
____________ |
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| Telephone
Number (if different from above) |
____________ |
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