Park University Library Registration Form

Please fill out the form below. The fields marked with an asterisks (*) are required.

Basic Information
Library User ID
*Park Student ID
*Title (Dr., Mr., Mrs., Ms.)
*First Name
Middle Name
*Last Name
Profile Name: (Check Box)	Administrator Faculty Graduate Student Staff Student

Demographic Information
Primary Address
*Street

*City
*State
*Zip/Postal Code
*Email	(A confirmation E-mail will be sent to this address)
*Phone
Fax

Permanent Address (If different from primary address)
Street

City
State
Zip/Postal Code
Phone

Department	(For Administration/Faculty/Staff Only)

Extended Information
Note	(Park ID#/Community User/ Date issued)
Comment	(Courtesy Card/Date issued/Librarians Initials)

Patron Acknowledgement and Agreement
1. A ten cent fine* (per item) will be incurred daily when the item(s) are not returned by the due date. *Fines will not exceed $2.00 2. A replacement fee will be incurred for item(s) that are not returned and assumed lost.

Patron Signature
Please Re-Enter your name for Verification that you agree to all of these facts being true to the best of your knowledge and belief, which is the equivalent of your signature.
*Name