Patron Registration Form

Apache County Library District

Patron Online Registration Form for residents of Apache County .
If applicant is a minor this form must be filled out by a parent or guardian and the digital signature must be the parent or guardian's signature.
Full Name*

First NameMiddle NameLast NameSuffix
Mailing Address (where you receive your mail)*

Apache County Mailing Address

Street Address Line 2

CityState

Zip Code
Physical Address (Street Address/Residence)*

Apache County Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
Alternate Email
example@example.com
Date of birth*

MonthDayYear
Date
Please be prepared to show a driver's license or State/Federal ID when you pick up your library card.
The above information will be shredded after completion of registration for your security. The Apache County Library District will keep only your signature on file.
Would you like to receive email notices for your account?

YesNo
By signing below, I agree to comply with the circulation and Internet policies of the Apache County Library District libraries or as they may be amended in the future by the Apache County Library District’s governing board. A current copy of the Library District’s circulation and Internet policies is posted and available to patrons at all branch offices of the district. I understand that it is my duty, as a patron of the library, to keep myself informed of any changes in Library District policies and procedures.
Name of applicant for card

First NameLast Name
Name-Parent/legal guardian:

First NameLast Name
Digital Signature (person requesting library card or parent/guardian signature if application is for a minor):

Clear
Today's Date*

MonthDayYear
Date
Signature (person requesting library card, to be signed when card is picked up):

____________________________________________________________
Signature - parent/legal guardian (minors under 18 years, to be signed when card is picked up)

___________________________________________________________
For Library Use Only:

Borrower ID: ________________
Library Use Only: Proof of Residency Provided: YES NO

Initials (staff receiving signature and distributing card): ___________
Should be Empty:

Apache County Library District

If applicant is a minor this form must be filled out by a parent or guardian and the digital signature must be the parent or guardian's signature.