System Headquarters: Osterhout free Library
71 South Franklin Street, Wilkes-Barre, PA 18701-1287 Phone: 570-823-0156 
FAX: 570-823-5477
www.luzerneco.lib.pa.us

Patron Registration Application
PLEASE PRINT

            Today's Date

   Name
 

    Last                 First                         Middle
Address
City           State        Zip    Phone  
City, Borough, Township in which you live County
E-mail  Address School District in which you live
Permanent Address (if different from above)
City  State    Zip    Phone
Place of Employment/School & Grade    Phone
Street  City State   Zip
(For Statistical Purposes Only)  Date of Birth  Male  Female
           MM     DD      YYYY        
Your library card entitles you to borrow materials from any of the member libraries in the
Luzerne County Library System and it may be used at any member library.
I apply for the right to use the libraries of the Luzerne County Library System and agree to comply with the rules and regulations.  I will pay all charges for Overdue, lost, or damaged materials borrowed on this card and will give immediate notice of any change of address.  I understand there is a charge to replace a lost card.  I agree that the library can reach me at any of the above information.
Signature of Applicant
   
Signature of Parents/ Legal Guardian (if applicant is under 18)
Library Use Only:
Identification
 Driver's License Number PA                  Expires     
 Non driver's License Number PA  Expires
 Vehicle Registration     Checkbook   Non-Resident Fee Paid
Utility Bill   Other  
Staff Initials  New  Renew  Barcode Number

Rev. 1/03

Back Mountain Memorial Library, Dallas   Hazleton Area Public Library   Hoyt Library, Kingston
 Marian Sutherland Kirby Library, Mountaintop   Mill Memorial Library, Nanticoke   Osterhout Free Library, Wilkes-Barre
Pittston Memorial Library   Plymouth Public Library   West Pittston Public Library   Wyoming Free Library