Surname: ............................................................................. Title: ...........................

First Names: .............................................................................................................

Address: ...................................................................................................................

...................................................................................................................................

.................................................................. Postcode: .............................................

Telephone No: .......................................... Mobile: .................................................

E-mail: ......................................................................................................................

Date of birth: ............................................................................................................

Guarantor Details (parent or legal guardian) Card no .......................................

Surname: ............................................................................. Title: ...........................

First Names: .............................................................................................................

Address (if different from above) ..............................................................................

...................................................................................................................................

.................................................................. Postcode: .............................................

Relationship to child: .............................................................................................

- I accept responsibility for library uses made by the child named above.

- I hereby apply for membership of Telford & Wrekin Libraries and I undertakethe byelaws, rules and regulations including ICT access policies.

Signed: .......................................................................... Date: .................................

Library Membership Application Form

Card No:

Membership type:

Staff use only Initials

ID seen for membership card: ................................................................

ID seen for casual use: ...........................................................................

System check: ........................................................................................

M/F: .........................................................................................................

It will help us to improve and plan services if you provide us with the followinginformation:

Age Ethnic Origin

........ 16-25 ............ Black or British 01

........ 26-35 ............ Asian or Asian British 02

........ 36-45 ............ White, UK/Irish/European 03

........ 46-55 ............ Chinese 04

........ 56-65 ............ Mixed/dual backgrounds 05

........ 66-75 ............ Other 06

........ over 75

The information you have provided on this form can be used to inform you offurther benefits and services available to you. The information will not be usedfor any other purposes or passed to any third parties. If you do not wish yourdata to be used for this purpose then please tick the box.

Concessionary membership is available for children and young people anddisabled customers. Please ask a member of staff for more information.

N.B Before issuing you with a library card we will need to see some form ofidentification that shows your name and address, such as a recent utility bill,bank statement, medical card or driving licence. If this is a problem for you wecan send a letter to you at your home address, which can then be used as ID tocollect your library card. ID is not needed for children under 16.