LPRL Patron Card Request Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Name(Required) First Middle Last Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Enter Email Confirm Email Phone(Required)Cell PhoneCell Phone Carrier(Required)Card Barcode #(Required)Number on the back of the card. The last four digits are your PIN number.ID #(Required)Drivers License "Customer Identifier" / Photo ID NumberThis field is hidden when viewing the formCard Barcode HelperThis field is hidden when viewing the formBarcode Image URL Lonesome Pine Regional Library Borrower's Agreement(Required) I agree to the Lonesome Pine Regional Library agreement and I understand that checking this box is equivalent to a signature and legally binds me to this agreement.I apply for the right to borrow materials from the library and will abide by its policies. I understand I am responsible for all materials borrowed on this card. I will pay fines, damages, or other charges to this card. I will give prompt notice of any change of address/name, or notify library of lost or stolen card. Referring MyRACE1 Staff's Email(Required)