Cora J. Belden Library Card Application
Fill out this form and bring it to the Library.

NAME: (please print)__________________________________________________________________
††††††††††††††††††††††††††††††††††† †††††† Last, First, Middle Initial
AGE: (check box)††† q Adult (13 or over) †††††††††† q Child (0-12) ††††††††††† ††††

DATE OF BIRTH:† _______________†† † †

GENDER:† (check box)††† qMALE qFEMALE

STREET ADDRESS: _____________________________________________________________
†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Apt.#

TOWN___________________________________________________ZIP__________††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

MAILING ADDRESS:____________________________________________________
(if different than above)††††††††††† Street††††††††††††††††††††††††††††††††††††††††††††††††††††††††††Apt.#
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††Town †††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††Zip

PHONE: (_____)________-____________ †††††† PHONE 2:† (_____)________-___________
††††††††††† Area Code††††††††††††††††††††††††††††††††††††††††††††††††††††††††Area Code

E-MAIL ADDRESS: (optional)_______________________________________________

SIGNATURE:___________________________________________________________

Parentís Signature for Grade Six (6) and below

 

FOR STAFF USE ONLY

Todayís Date___________________††††††††††††††††††††††††††††††††††††††††† Privilege Expires: ___/__ _/___

Verify Customerís ID w/Current Address: _____________†††††††††† Staff Initials_____________________††

Customer Barcode:††† 22534 --__________________--________________

Residency Code: __________________(UserCat1)