Ill. Admin. Code tit. 23, § 3010.EXHIBIT D
| ILLINOIS STATE LIBRARY CIRCULATION 300 S. SECOND ST. SPRINGFIELD IL 62701-1796 | ||||||||||||||||||
| ILLINOIS STATE LIBRARY CARD APPLICATION FORM − REGULAR CARD | ||||||||||||||||||
| DATE | NAME | |||||||||||||||||
| (last) | (first) | (m.i.) | ||||||||||||||||
| AGENCY INFORMATION | HOME ADDRESS INFORMATION | |||||||||||||||||
| AGENCY | STREET | |||||||||||||||||
| DIV. | CITY | |||||||||||||||||
| ROOM # | STATE | |||||||||||||||||
| STREET | ZIP | |||||||||||||||||
| CITY | PHONE | |||||||||||||||||
| ZIP | PLEASE CHECK TYPE OF EMPLOYMENT: | |||||||||||||||||
| PHONE | Full time | |||||||||||||||||
| FAX | Contractual | Ending Date | ||||||||||||||||
| Temporary | Ending Date | |||||||||||||||||
| STAFF USE ONLY: GOVERNMENT AFFILIATION | Intermittent | Ending Date | ||||||||||||||||
| 1. GS 2. GV 3. LS | Other | Ending Date | ||||||||||||||||
| STAFF USE ONLY | ||||||||||||||||||
| Library Card Expiration Date: | ||||||||||||||||||
| 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 | Check this box in lieu of signature to submit application electronically | |||||||||||||||||
| 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)