Centralia Public Library: Library Card Application
This form must be completed by an adult. If you are younger than 18 years old, please ask your parent to complete this application, as he/she will need to have a library card as well and be responsible for your account at the library.
SECTION 1: MUST BE COMPLETED BY AN ADULT
FIRST NAME: *
Your answer
LAST NAME: *
Your answer
Driver's License or Photo I.D. Number: *
Your answer
Phone Number: *
Your answer
Email Address (For Receiving Overdue Notices Only):
As a courtesy, you will receive an email reminder 5 days before your library items are due, and you will receive additional reminders once your items become overdue.
Your answer
Street Address: *
Your answer
City: *
Your answer
Zipcode: *
Your answer
Would you like to obtain a library card for any of your minor (age 17 and under) children? *
Required
SECTION 2: FOR ADULTS WITH MINOR CHILDREN
If you have no children in need of a library card, please scroll to the very bottom of this application to read and provide an esignature on the final question before submitting.
Full Name of Minor Child #1 to Receive Library Card:
Each child must be listed separately
Your answer
What is the birthdate for minor child #1?
MM
/
DD
/
YYYY
Does child #1 live at the same address as you?
Answer Yes or No. If No, please include the child's full address below.
Your answer
Does child #1 have computer privileges?
Full Name of Minor Child #2 to Receive Library Card:
If you do not have another child, please scroll to Section 3 to provide an esignature before submitting this application.
Your answer
What is the birthdate for minor child #2?
MM
/
DD
/
YYYY
Does child #2 live at the same address as you?
Answer Yes or No. If No, please include the child's full address below.
Your answer
Does child #2 have computer privileges?
Full Name of Minor Child #3 to Receive Library Card:
If you do not have another child, please scroll to Section 3 to provide an esignature before submitting this application.
Your answer
What is the birthdate for minor child #3?
MM
/
DD
/
YYYY
Does child #3 live at the same address as you?
Answer Yes or No. If No, please include the child's full address below.
Your answer
Does child #3 have computer privileges?
Full Name of Minor Child #4 to Receive Library Card:
If you do not have another child, please scroll to Section 3 to provide an esignature before submitting this application.
Your answer
What is the birthdate for minor child #4?
MM
/
DD
/
YYYY
Does this child #4 live at the same address as you?
Answer Yes or No. If No, please include the child's full address below.
Your answer
Does child #4 have computer privileges?
SECTION 3: ALL ADULTS MUST ESIGN TO AUTHORIZE THE APPLICATION
Centralia Public Library requires that you certify your application by submitting an electronic signature. If you agree to abide by all of the library's policies (Borrower's Policies: http://www.centraliapubliclibrary.com/policies/borrowers-rules-policies/), please type your initials below, to indicate that all information completed on this form is accurate and true. *
Example: CPL
Your answer
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