Library Registration Form

Date of Application

Name (Please Print)

(Last ) (First) (Middle)

Other

ID Barcode

Campus ID Number ( CSB/SJU Only / number on front of ID)

Campus Address:

Department

Building

Phone

Home Address:

	Street
	City, State, Zip
	Phone

Work Address:

	Street
	City, State , Zip
	Phone

E-Mail Address:

If you are currently not affiliated with this University, Please describe your reasons for wanting Library privileges:

Are you currently a patron at another educational Institution?

	Yes
	No

Institution Name

NOTE:

-Borrower cards are to be used ONLY by the person whose name is on the card.

-You must present your card for service.

I agree to observe Clemens/ Alcuin Library's borrowing regulations and to return all items on time. Failure to do so may result in loss of borrowing privileges.

Signature ( Please Print Your Name)

Forms Manager

Library Registration Form