APPLICATION FOR FREE LIBRARY SERVICE - Page 1

(Please Print or Type:)
PATRON NAME (OR FACILITY):_________________________ (Last)(First)(Initial)

ADDRESS:______________________________________ (Street or PO Box)

_______________________________________________ (City) (County) (Zip)

PHONE #:___________BIRTH DATE: __/__/__ (mo/dy/yr) __Female __Male

ALTERNATE CONTACT: (if applicant is a student, name parent/guardian)

NAME:_________________________________ DAY PHONE:________

ADDRESS:______________________________________ (Street or P.O. Box)

_______________________________________________ (City) (County) (Zip)

CONFIDENTIALITY STATEMENT: All library records are confidential pursuant to Montana Code annotated 22-1-1103.

VETERANS: ___Please check if you have been honorably discharged from the U.S. Armed Forces. By law, Veterans are given preference in lending library materials.

INSTITUTIONS: All Talking Book materials may be loaned to individuals who qualify, to institutions such as nursing homes and hospitals and to schools for the blind or physically handicapped for use by such qualifying persons only. These materials may also be used in public or private schools where handicapped students are enrolled. The students in public or private schools must be certified as eligible on an individual basis and must be the direct and only recipients of the materials and equipment.