§3010.EXHIBIT D. Illinois State Library Card Application Form: Regular Card

 

ILLINOIS STATE LIBRARY CIRCULATION 300 S. SECOND ST. SPRINGFIELD IL 62701-1796

ILLINOIS STATE LIBRARY CARD APPLICATION FORM − REGULAR CARD

DATE

NAME

(last)

(first)

(m.i.)

AGENCY INFORMATION

HOME ADDRESS INFORMATION

AGENCY

STREET

DIV.

CITY

ROOM #

STATE

STREET

ZIP

CITY

PHONE

ZIP

PLEASE CHECK TYPE OF EMPLOYMENT:

PHONE

Full time

FAX

Contractual

Ending Date

EMAIL

Temporary

Ending Date

STAFF USE ONLY:  GOVERNMENT AFFILIATION

Intermittent

Ending Date

1.        GS 2.        GV 3.        LS

Other

Ending Date

STAFF USE ONLY

Library Card Expiration Date:

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

Check this box in lieu of signature to submit application electronically

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)