TITLE 23: EDUCATION AND CULTURAL RESOURCES
SUBTITLE B: CULTURAL RESOURCES
CHAPTER I: SECRETARY OF STATE
PART 3010 ILLINOIS STATE LIBRARY, LIBRARY OPERATIONS DIVISION
SECTION 3010.EXHIBIT C ILLINOIS STATE LIBRARY CARD APPLICATION FORM: COURTESY CARD



Section 3010.EXHIBIT C Illinois State Library Card Application Form: Courtesy Card

 

ILLINOIS STATE LIBRARY

CIRCULATION

300 S. SECOND ST.

SPRINGFIELD IL 62701-1796

ILLINOIS STATE LIBRARY CARD APPLICATION FORM COURTESY CARD

DATE

 

NAME

 

 

 

 

 

(last)

(first)

(m.i.)

 

HOME INFORMATION

 

PUBLIC LIBRARY CARD INFORMATION

STREET

 

LIBRARY

CITY

 

CARD #

ZIP

 

EXPIRATION

PHONE

 

STAFF USE ONLY

WORK INFORMATION

 

Library Card Expiration Date:

BUSINESS

 

 

STREET

 

 

CITY

 

 

ZIP

 

 

PHONE

 

 

E-MAIL

 

 

I HEREBY PROMISE TO ASSUME FULL RESPONSIBILITY FOR ANY LIBRARY MATERIALS BORROWED ON THIS CARD. I WILL RETURN THE MATERIALS ON OR BEFORE THE DATE DUE, PAY RETURN POSTAGE OR EXPRESS, AND PAY FOR ANY LOSSES OR DAMAGES. ALL PATRON RECORDS ARE KEPT STRICTLY CONFIDENTIAL.

SIGNATURE

 

 

 

SIGNATURE OF RESPONSIBLE PARTY FOR CHILDREN UNDER 13

 

 

 

 

STAFF USE ONLY

Barcode

 

Staff Initials

 

This application is subject to review by the Illinois State Library Circulation Staff. Applicant will be contacted for further information if necessary.

 

(Source: Amended at 36 Ill. Reg. 3217, effective February 16, 2012)