Today's Date             
Name                     
Address                  
City, State & Zip        
Date of Birth (mm/dd/yy)      PHONE 
E-mail address      CELL PHONE 

Gender:     Male  Female

I am filling in this application to:

Get my first library card in Nassau County Replace a lost card

Change the name on my card Change the address on my card

Change my library district (because I have had a card at another Nassau County Library - my last address appears below)

My Previous Full Address: 
If you are NOT A PORT WASHINGTON RESIDENT, but are EMPLOYED in Port Washington, please indicate the following:

Employer's Name:    
Employer's Address: 
Employer's Phone: