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

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Staff Initials

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