2. Note: Residence or property-ownership in Polk County, FL is required to obtain a free Polk County Library Cooperative card with this form. If you do not live or own property in Polk County, please visit your nearest PCLC library to apply for a card.
   
   

4. First Name*
5. Last Name*
7. Middle Name
8. Suffix
10. Birth Date*
    Birth Date
12. Mailing Address*
14. City*
15. State*
16. Zip*
18. Physical Address, if different
20. City
21. State
22. Zip
24. Primary Phone Number*

    Enter your phone number 

26. Backup Phone Number

    Enter your phone number (optional)

28. Email address
30. How should we contact you?*
    -- Select One --PhoneEmailText
32. Request a PIN for digital Account access and borrowing eBooks
34. Which type of card would you prefer?

    1. Standard card
    2. Keychain card
35. How do you want to get your new library card?

    1. Pick it up
    2. In the mail

37. A valid photo ID is required to apply for a library card. Please upload a photo or copy of your ID. If your photo ID does not have your current, local address, please upload additional proof of address.

39. Upload photo ID*

41. Acceptable forms of photo ID include but are not limited to Driver’s License, Temporary Driver’s License, State ID, passport, Military ID, Student ID.

    Acceptable proofs of address include but are not limited to voter registration card, USPS change of address notice, current bill, rental agreement, vehicle registration. 

43. By submitting this form, you agree to accept responsibility for replacement costs, repairs, and all fines and fees associated with the person registered on this application.

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field