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:

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: