Library Card Application

LIBRARY CARD APPLICATION FORM

BERKLEY PUBLIC LIBRARY
Name*

Legal First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Driver's License or State ID Number
Resident Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Primary Phone*

Area CodePhone Number
Cell Carrier for Text Notifications
e.g. AT&T, Verizon, T-Mobile, etc.
STATEMENT OF RESPONSIBILITY

I certify that the information on this form is correct. I agree to abide by the rules and regulations of the library and accept full responsibility for all materials checked out on this card (including all fines and damages charged). I will give notice of any change in my address or loss of my card.

I understand it is my responsibility to check my patron account and that Berkley Public Library cannot be held responsible for notices that do not reach my address (mail or email).
Patron Signature*

Clear
Signature date*
PARENT OR GUARDIAN STATEMENT OF RESPONSIBILITY

Minors under the age of 18 must have the signature of their parent or guardian. As the parent or guardian of the minor named above, I give permission for them to borrow materials from the library. I agree to pay all fines and damages to their card, to be responsible for supervising their selection of materials, and to make sure they obey library rules.
Parent or Guardian Signature

Clear
Signature date
Should be Empty:

LIBRARY CARD APPLICATION FORM