Ill. Admin. Code tit. 23, § 3010.EXHIBIT C
| ILLINOIS STATE LIBRARY CIRCULATION 300 S. SECOND ST. SPRINGFIELD IL 62701-1796 | |||||||||||||||
| ILLINOIS STATE LIBRARY CARD APPLICATION FORM – COURTESY CARD | |||||||||||||||
| DATE | NAME | ||||||||||||||
| (last) | (first) | (m.i.) | |||||||||||||
| HOME INFORMATION | PUBLIC LIBRARY CARD INFORMATION | ||||||||||||||
| STREET | LIBRARY | ||||||||||||||
| CITY | CARD # | ||||||||||||||
| ZIP | EXPIRATION | ||||||||||||||
| PHONE | STAFF USE ONLY | ||||||||||||||
| WORK INFORMATION | Library Card Expiration Date: | ||||||||||||||
| BUSINESS | |||||||||||||||
| STREET | |||||||||||||||
| CITY | |||||||||||||||
| ZIP | |||||||||||||||
| PHONE | |||||||||||||||
| I HEREBY PROMISE TO ASSUME FULL RESPONSIBILITY FOR ANY LIBRARY MATERIALS BORROWED ON THIS CARD. I WILL RETURN THE MATERIALS ON OR BEFORE THE DATE DUE, PAY RETURN POSTAGE OR EXPRESS, AND PAY FOR ANY LOSSES OR DAMAGES. ALL PATRON RECORDS ARE KEPT STRICTLY CONFIDENTIAL. | |||||||||||||||
| SIGNATURE | |||||||||||||||
| SIGNATURE OF RESPONSIBLE PARTY FOR CHILDREN UNDER 13 | |||||||||||||||
| STAFF USE ONLY | |||||||||||||||
| Barcode | Staff Initials | ||||||||||||||
| This application is subject to review by the Illinois State Library Circulation Staff. Applicant will be contacted for further information if necessary. | |||||||||||||||
(Source: Amended at 36 Ill. Reg. 3217, effective February 16, 2012)