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. All residents of and/or real property owners in the City of Charlottesville, and the counties of Albemarle, Greene, Louisa and Nelson are eligible to obtain free library cards. All others will have a $30 annual 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

---

Staff Use Only

Date	Intitials	Barcode #
		217430