Member#
, Card Number*
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MEMBER PERSONAL DETAILS
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checked>F
checked> M
Date of Birth
(
)
Title
Initials
Given Names*
Surname*
Prefered Name
value=" ">No Title
>Miss
>Mrs
>Ms
value="Mr" >Mr
>Dr
>Sir
Ethnicity
Ethnicity Notes
Membership Category*
>
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MEMBER ADDRESS
Postal Address*
Town*
Area
Street Address if different
Town
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MEMBER CONTACT DETAILS
Phone (Home)
Fax
Email
Text Messaging
Phone (Day)
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ALTERNATE CONTACT DETAILS
Name*
Phone
Relationship*
>
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LIBRARY USE
Notes
Notes
FLAGS
>Yes
>No
/
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