Distance Learning Services, Library Card Application - Library

Distance Learning Services - Library Card Application

This application is for students who are ONLY enrolled in Distance Learning courses and cannot visit a campus library.

Please provide the following information: (* indicates a required field)

*First name:

Middle name:

*Last name:

*CCRI ID #:

CCRI barcode:

Your CCRI Barcode # is the 14-digit number just below the barcode strip on your CCRI ID card. Skip this field if you do not have a CCRI ID card.

*Email address (CCRI email preferred):

Alternate email address:

*Phone number:

*Home address:

Street
City State Zip code

Mailing address (if different from home address):

Street
City State Zip code

*Distance Learning course(s) enrolled in:

*Age:

Under 18 years of age 18 years of age or older

NOTE: Students under age 18 must have a parent or guardian sign this form.

* I agree

to abide by the library's rules and regulations and to be responsible for material charged out to me. I understand that failure to return materials borrowed may result in a $100 fee per item, the loss of library privileges and the withholding of grades, transcripts, diplomas, and/or registration.

* Please type your name to act as your signature:

If under 18 years of age:

Parent/guardian signature:

Parent/guardian email address:

Comments: