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 (Required for Communication):_______________________________________________________
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: 6/11/19 3:32 PM