Bookmobile Library Card Application

2. Bookmobile Library Card Application (For Residents located in Nursing Homes and/or Assisted Living Communities Only!)

   To register for a library card, you will need to complete this form and provide current identification with proof of your address.  The information on this form is used to maintain a complete list of library patrons and will be used to record the location of library materials.

6. PATRON INFORMATION
8. First Name*
9. Last Name*
11. Nursing Home/Assisted Living Community*
13. Resident's Address
15. City
16. State
17. Zip Code
19. Phone Number*
20. Secondary Phone Number
22. Email Address
24. Birth month*
25. Driver's License
29. Reading Interests/Favorite Authors

    List who you enjoy reading along with key terms as to what type of materials you enjoy reading. Example: Romance, Nora Roberts, paranormal

31. I agree to be responsible for materials borrowed with this card, for all fines incurred, and for loss and/or damage of materials charged to it.

33. Signature*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field