Applicant's Information:
    First Name:
    Last Name:
    Date of Birth:
    Day:
    Year:
    Email:
    Gender:
    FemaleMale
    Address (Line 1):
    Address (Line 2):
    City:
    State
    Zip:
    Phone:
    School District:
    Borough/Township:
    County:
    Permanent Address - if different from above
    Address (Line 1):
    Address (Line 2):
    City:
    State
    Zip:
    Phone:
    Employer/School Information:
    Employer/School Name:
    Grade:
    Address (Line 1):
    Address (Line 2):
    City:
    State
    Zip:
    Phone:

    Please select one of the below options:

    I AGREE TO THE FOLLOWING TERMS:

    Your library card entitles you to borrow materials from any of the member libraries in the Luzerne County Library System and it may be used at any member library. I apply for the right to use the libraries of the Luzerne County Library System and agree to comply with the rules and regulations. I will pay all charges for overdue, lost, or damaged materials borrowed on this card and will give immediate notice of any change of address. I understand there is a charge to replace a lost card. I agree that the library can contact me for reasons related to my borrowing responsibilities using any of the above information.

    Signature(s)
    Signature of Applicant:
    Signature of Parent/Legal Guardian: