Jefferson-Madison Regional Library

Library Card Application

Fill out the form and PRINT. Present this at any library branch along with identification with your name and current address. If out-of-state, there is a $23.00 fee.

Last Name	First Name	Middle Initial
Mailing Address (include Apt. #)
City	State	Zip Code
Telephone (include area code)	Birthday (mm/dd/yyyy)	Social Security or Drivers License # (optional)
Sex Male Female	City or County of Residence Albemarle Charlottesville Greene Louisa Nelson Out of Area	School (optional)
Your residential or permanent address if different from above (Number, Street, Apt #)
City	State	Zip Code
E-mail address (Optional. Holds notices, overdue notices and courtesy notices will be sent by e-mail. Please be exact as e-mail is often case sensitive)

I agree to be responsible for all materials charged on my library card; to report a lost card at once; to observe library rules; to pay promptly all charges; and to notify the library of any name or address changes.
Signature of Applicant

For Parent or Guardian of Minor Applicant (Under 16)
I acknowledge that this library card entitles my child to complete access to all library materials. I assume responsibility for library materials borrowed by this child from the library.
Parent's Name

Signature of Parent

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Staff Use Only

Date	Intitials	Barcode #
		217430