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2. First Name*
3. Last Name*
4. Middle Initial*
6. Residence Address*
8. City*
9. State*
10. Zip Code*
12. Date of Birth*
    Date of Birth
16. Parent/Legal Guardian Name*
17. Sex (M/F)*
19. Address*
21. City*
22. State*
23. Zip Code*
25. Phone Number*
26. Email*
30. Which Library location would you like to pick your Library Card up from?*
    -- Select One --R.C. Miller LibraryTheodore Johns LibraryElmo Willard LibraryDowntown Main Library
34. I understand that *

    1. I understand all

    1) I am responsible for all items borrowed with this library card, including late, lost, or damaged materials.

    2) I will notify the library immediately if the card is lost or stolen.

    3) I will notify the library of a change of address and/or telephone number. (By City Ordinance, it is unlawful for a non-resident to use the card unless Beaumont city property taxes are paid or an annual non-resident fee is paid.)

    4)  I understand that the card is city property and I must return it upon request.

    5) Youth card holders also have access to the adult collection. I am responsible for my child's selection of materials.

    6) Youth signature authorizes parent access to library records.

36. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
38. Electronic Signature of Parent or Guardian*
40. Electronic Signature of Youth*
42. Photo of Parent/Legal Guardian Driver's License*

    Please upload a scan or photo of your valid Driver's License with your name, face, and address clearly visible. 

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44. Submit

* indicates a required field