Designed for Evergreen - Rev. February 23, 2012
Please print everything except the signatures.

Paid $35 for family membership, date________ Paid $35 for gift membership, date________ Donation, date________ Staff signature___________________

Cleveland Library Card Barcode (for library use only) - ______________

First Name* - ___________________ Middle Name - ____________________

Surname (Last Name)* - ________________ Suffix - __________ Alias - ____________

Date of Birth* (use format YYYY-MM-DD, like 1980-12-25) - ______-____-________

Primary ID* - NC Driver's License ________________ or NC ID ________________

E-mail Address* - _______________________________________

Phone (Day)* - _____ - _____ - __________ Example 919-715-6500 Ext. 20

Phone (Night)* - _____ - _____ - __________

Phone (Other/Cell)* - _____ - _____ - __________

Home Library* - Main Cleveland Library ______ Branch ______________ Bookmobile ___ Other _____________

Label (for library use only) ____________ 9-Dgit ZIPCode* - _________ - _______

Street Address 1* - ____________________________________________

Street Address 2 - ____________________________________________

City* - __________________________ County* - _________________

State* - ____________ Country - _______ Other ______ Within City Limits* _____

Profile Group - (for library use only) Patron* - _______ Staff _____ Teacher _______

- (for teachers) School & Address - _______________________________________________________

Internet Access Level* (for library use only) -_Unfiltered__

Category* (for library use only) - ___________

Applicant's Signature* ________________________________________ Date* - _________

If under age 18: Student ID (for library use only)* - ______________________________

- Parent or Guardian's Name PRINT (last, first)* - __________________, ________________________

- Parent's or Guardian's Signature* - ________________________________________ Date* - _______

Are you interested in volunteer work? Yes ___ N ___