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2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip

13. Note:  Must be able to receive mail at this address.

15. Phone
16. Email Address
18. Birthdate

    Note: Must be 18+.

20. I authorize the Library to speak to the following individual about my account (optional):

22. Representative Name
23. Representative Phone Number
25. Do you have a visual disability or physical limitation that prevents you from reading standard print? (Note: your answer does not impact eligibility to receive Books By Mail)

    1. Yes
    2. No
27. Do you wish to receive LARGE PRINT BOOKS?

    1. Yes
    2. No
28. Do you wish to receive AUDIO BOOKS?

    1. Yes
    2. No
30. Number of library materials desired in each mailing:
32. To avoid duplication, may we keep a list of titles sent to you?

    1. Yes
    2. No
34. Certification*

    1. I certify that I am unable to physically visit the library due to illness, disability or visual impairment, on a temporary or permanent basis
36. Tennessen Warning

    Minnesota law and Anoka County Library policy protect the privacy of data in your library record. Information we gather to issue you a card and information which links you to the material you borrow is private. It may not be disclosed except for library purposes, unless ordered by a court. Items returned on time are removed from your record when checked in. Overdue items and related charges remain on your record until paid. Unreturned items become a public debt and are no longer protected data. Records of requested material are kept until you receive the material. The law allows the library to release your requested materials to a family member or other person who resides at your address. You may request that materials NOT be released to anyone other than yourself. To make this request, please see library staff. If you are under the age of 18, the information in your library record is available to your parent or guardian. You may ask to have this information withheld by completing a Request to Withhold Release of Information to a Parent or Guardian form. We can only withhold this data from your parent/guardian if it is determined that it is in your best interest to do so.

38. Submission Statement

    By submitting this form electronically you are agreeing to share this information with the Library.  You are responsible for all materials borrowed with your card.  A lost, stolen, or damaged card must be reported within 60 days of the occurrence. Failure to do so will cause you to be liable for any fraudulent activity and expenses that might occur on your account. Replacement cards are available. Notify Anoka County Library of changes in name, address, or phone number.

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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field