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2. General Information
4. First Name*
5. Middle Initial
6. Last Name*
7. Date of Birth*
   Date of Birth
9. Street Address*
11. Apartment Number
12. City*
13. State*
14. Zip Code*
16. Email Address
17. Phone Number
21. Type of Card - Select One
23. New Adult/Teen

    1. (ages 14+)

    I will be responsible for any loss, damage, or fines for materials borrowed on my library card.

25. New Children's

    1. (13 & under)

    I authorize my child to borrow any materials from the Winooski Memorial Library, without restriction. I will be responsible for any loss, damage, or fines for materials borrowed on my child’s library card.

27. Renewal/Replacement

    1. If known, please provide your current Winooski Memorial Library card number below.
29. Library Card Number
33. Card Eligibility

    Please check only one. Provide physical proof of address.

35. Resident

    1. I live in Winooski
36. Home Address
38. Employee

    1. I work in Winooski
39. Work Address
41. Student

    1. I go to school in Winooski
42. School Address
44. Property Owner

    1. I own a property in Winooski
45. Property Address
47. Vermont Resident

    1. (address at top of form)
51. Preferred Method of Contact*

    1. Email

    1. Phone

    1. Postal Mail
53. Signature*

    1. Yes

    By clicking yes, I hereby electronically sign this document and attest that the information provided here is true.

55. Parent or Guardian Signature

    1. Yes

    Required for children under 13. By clicking yes, I hereby electronically sign this document and attest that the information provided here is true.

Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field