Community User

SMSU Library
Community Library User Information

Note: This form MUST be accompanied by a valid public library card and driver’s license.

Please Print Clearly

Drivers License #: _________________________________________________________

Last Name:___________________________________First Name:___________________M.I.______

Home Address: Street:_____________________________________________________

City:________________________State:________Zip Code:___________________

Telephone Number:_____-_____-_____

E-mail:____________________________________________________________________

Library or school name:_______________________________________________________

Library card number:_______________________City, State, Zip:______________________

I accept responsibility for materials borrowed and understand that I must pay for all materials which are lost, damaged, and/or not returned, as well as a $10 fee for each item that is lost, damaged, not returned and/or overdue.

_________________________________ _____________________________
Signature                                             Date

_________ I verify that I am 18 years of age or older.


If user is under 18 years of age, please complete the following.

Name of Parent/Guardian:________________________________________________________________________

Address (if different from above):__________________________________________________________________

Telephone Number (if different from above): _____-_____-_____

The minor has my permission to use and borrow materials from SMSU Library. I accept responsibility for materials borrowed by the above user and understand that I must pay for all materials which are lost, damaged, and/or not returned, as well as a $10 fee for each item that is lost, damaged, not returned and/or overdue.

_________________________________ _____________________________
Signature                                               Date
++++++++++++++++++++++++++Do not write below this line. For library use only++++++++++++++++++++

Barcode number assigned_____________________________________________________________________

Date entered_____________________________________ Initials________________
 

Last Modified: 1/31/17 2:48 PM