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Individual Borrower's Application
Applicants must be Illinois residents over age 18.

The Individual Borrower’s Application Form is also available in PDF format.

Fields marked with an * are Required.
* Name:
* Employer:
* Work Address (no P.O. boxes):
* City:
State: Illinois
* ZIP Code:
* County:
* Phone: ( )


* Home Address (no P.O. boxes):
* City:
State: Illinois
* ZIP Code:
* Phone: ( )
* E-mail:
* Drivers License or State ID #:


DHS--Community Prevention funded? Yes No
DHS--Disability/Rehabilitation funded? Yes No


Borrower Type (Check one only)
Chicago Public Schools staff
College or university staff
College student—Over 18
DHS—Community Prevention staff
DHS—Disability & Rehabilitation staff
Faith community
Health care
IL Dept. of Child. & Family Services staff
IL Dept. of Corrections staff
IL Dept. of Public Health staff
IL Dept. of Transportation staff		 IL State Police
Law enforcement
Library staff
Local government
Private business
Private individual—Over 18
Private school staff
Public school staff
Social service
State government
Other (Specify):

How Did You Learn About Us?
Training
Prevention Forum
Library/Clearinghouse News
PFI exhibit
Co-worker
Internet search
Other (Specify):

I agree to comply with library policies, rules and regulations, be responsible for
materials loaned to me, and give prompt notice of change of agency or address.

* I Agree Date:

        

PLEASE NOTE: You must also mail or fax a clear photocopy of your driver’s license or state photo ID to:

2800 Montvale Drive, Springfield, IL 62704
Phone 217.793.7353
Toll-Free in Illinois 800.252.8951
Fax: 217.726.7390

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