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2. CARD HOLDER'S INFORMATION
   Please enter the full name without abbreviations.
4. First Name*
5. Middle Name*
6. Last Name*
8. Jr./Sr.
9. Birthdate*
10. 4-Digit PIN*
    A password to access our online services. Must be four numbers.
14. APPLICANT'S INFORMATION
    If this card is for someone under 18, this section should use the information for the parent or legal guardian.
16. Driver's License Number*
18. Address*
19. Apartment Number
21. City*

    The following are the only cities/townships eligible for a LWM library card:

    1. Richmond
    2. Richmond Township
    3. Casco
    4. Columbus
22. Zip Code*
24. Home Phone
25. Mobile Phone
26. Wireless Carrier
27. Notification Preference*

    1. Email
    2. Text
29. Email
30. Would you like your checkout history to be kept in your record?*

    1. Yes
    2. No
34. PARENT/GUARDIAN INFORMATION
    Only fill out this section if you are applying for someone under 18 years of age.
36. First Name
37. Middle Name
38. Last Name
40. Relationship

    1. Mother
    2. Father
    3. Legal Guardian
41. Birthdate
42. NOTE: The parent or legal guardian must sign the service agreement
46. ACCOUNT PERMISSIONS
    The Michigan Library Privacy Act prohibits the sharing of your account information. You may waive this protection and grant full access to certain individuals. Those with access may see your checkouts, pay your fines, and obtain your holds. At your discretion, please list who you would like to grant access. NOTE: If these individuals are library patrons, their library account must be in good standing to have access.
48. Person 1
49. Person 2
53. SERVICE AGREEMENT
    (Read and sign to accept)
55. *I hereby apply for a borrower's card and agree to abide by the rules and regulations of the library.
57. *I agree that I am responsible for all use of this card and agree to pay all fines and fees that are charged to my account.
59. *In the event of a lost card or change in my address, I agree to give the library prompt notice.
61. *I certify that the information on this application is true and further understand that any fraudulent statement may result in the cancellation of library privileges.
63. *I understand that the library does not charge a fee for text messaging, but that my cellular plan may charge standard text messaging rates.
65. Electronic Signature*
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field