Fillable Form PLPL-01 (Revised 08/2014): Library Card Application (TOWN OF PINETOP-LAKESIDE)

Fill Online, Printable, Fillable, Blank Form PLPL-01 (Revised 08/2014): Library Card Application (TOWN OF PINETOP-LAKESIDE) Form

Use Fill to complete blank online TOWN OF PINETOP-LAKESIDE (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form PLPL-01 (Revised 08/2014): Library Card Application (TOWN OF PINETOP-LAKESIDE)

On average this form takes 21 minutes to complete

The Form PLPL-01 (Revised 08/2014): Library Card Application (TOWN OF PINETOP-LAKESIDE) form is 2 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 75 other fields

Country of origin: US
File type: PDF

U.S.A. forms for TOWN OF PINETOP-LAKESIDE

BROWSE TOWN OF PINETOP-LAKESIDE (AZ) FORMS
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Library Card Application
Form PLPL-01 (Revised 08/2014)
A library card is available for free to residents of Pinetop-Lakeside, as well as residents of Navajo County. Your library card will allow you to
borrow library materials, download digital media, access online databases, and use library computers.
You must complete this application, present a valid photo identification (i.e., a AZ DL/ID, Passport ID, Military ID, Tribal ID, or School ID), and
proof of a mailing address (i.e., a piece of postmarked mail). If you are under the age of 18, your parent/guardian must apply for a library
card before we can issue you a library card. Print clearly in blue or black ink and complete all fields below.
Section A – Adult Applicant
Today’s Date (MM/DD/YYYY)
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Proof of Identification (AZ DL/ID or Alt. ID)
Mailing Address
City
State
Zip Code
Local Street Address or Winter Address (if different from mailing)
City
State
Zip Code
Email Address
Primary Phone Number (XXX-XXX-XXXX)
Alt. Phone Number (XXX-XXX-XXXX)
Section B – Adult Applicant Agreement
Your Privacy: In accordance with A.R.S. §41-151.22, Pinetop-Lakeside Public Library shall not allow disclosure of any record or other information which identifies a
user of library services as requesting or obtaining specific materials or services or as otherwise using the library. Such records are only disclosed if necessary for the
reasonable operation of the library; on written consent of the user; on receipt of a court order; or if required by law (such as the USA Patriot Act, Public Law 107-56).
I agree to observe all rules and regulations of the library, to pay all fees charged against me or my family for the damage or loss of library materials and any
overdue charges, and to give immediate notice of any change of address, phone number, email, or lost card. (There is a $1.00 replacement fee for a lost card.)
Primary Applicant Signature:
Date:
Section C – Secondary Adult Applicant
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Proof of Identification (AZ DL/ID or Alt. ID)
Email Address
Primary Phone Number (XXX-XXX-XXXX)
Alt. Phone Number (XXX-XXX-XXXX)
Section D – Secondary Adult Applicant Agreement
Date:
Your Privacy: In accordance with A.R.S. §41-151.22, Pinetop-Lakeside Public Library shall not allow disclosure of any record or other information which identifies a
user of library services as requesting or obtaining specific materials or services or as otherwise using the library. Such records are only disclosed if necessary for the
reasonable operation of the library; on written consent of the user; on receipt of a court order; or if required by law (such as the USA Patriot Act, Public Law 107-56).
I agree to observe all rules and regulations of the library, to pay all fees charged against me or my family for the damage or loss of library materials and any
overdue charges, and to give immediate notice of any change of address, phone number, email, or lost card. (There is a $1.00 replacement fee for a lost card.)
Secondary Applicant Signature:
Date:
Last Name:
Section E – For Library Use Only
Adult Applicant Library Card Number
Group ID (if applicable)
Proof of Mailing Address
Yes No; If “No”, date postcard mailed:
Date postcard returned undeliverable or Date card issued:
Secondary Adult Applicant Library Card Number
Initial Registration By:
Initials Date
Final Registration By:
Initials Date
pinetoplakesidelibrary.org
1595 Johnson Drive, Pinetop-Lakeside, AZ 85929 | Phone 928-368-6688 | Fax 928-368-8963 | info@pinetoplakesidelibrary.org
click to sign
signature
click to edit
click to sign
signature
click to edit
Library Card Application
Form PLPL-01 (Revised 08/2014)
Section F – Additional Applicants (under age 18)
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
Additional Cardholder
Last Name
First Name
Middle Initial
Gender
Male Female
Date of Birth (MM/DD/YYYY)
Library PIN (password to access library computers)
Library Card Number
Responsibility Policy
CHILDNOPAY CHILD-PAY
User Profile
JUV-LAR YA
pinetoplakesidelibrary.org
1595 Johnson Drive, Pinetop-Lakeside, AZ 85929 | Phone 928-368-6688 | Fax 928-368-8963 | info@pinetoplakesidelibrary.org
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form PLPL-01 (Revised 082014): Library Card Application (TOWN OF PINETOP-LAKESIDE)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document