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

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.