If the person named above is a minor.
The signature of a parent or guardian must be provided.
Signature: _____________________________ Date: 22-Jan-2021
OR
I certify that the applicant named above is requesting library service and is unable to read or use regular printed material for the reason indicated on this form.
Please Note:This section must be signed by the certifying authority spoken of above.
Signature: _____________________________ Date: 22-Jan-2021