Palliser Regional Library

Name

First Name

Middle Name

Last Name

Parent / Guardian

Name on Identification (only if different from above)

If the name on your identification is different than specified above, please indicate the full name on your identification.

First Name

Middle Name

Last Name

Use this name on identification for print or phone notices
(First name and last name are required for this option)

Birthdate

Birth Date

Address

Mailing Address

City/Town

Province

Postal Code

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Contact Information*

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Phone Number

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