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2. First name*
3. Last name*
5. Address
7. City
8. State
9. Zip
11. Phone number*
12. Email*
14. Date of birth (if under 18)
15. Parent's full name
17. Campbell County resident?*

    1. Yes
    2. No
18. I want to pick up my new library card at*

    1. Campbell County Public Library in Gillette
    2. Wright Branch Library
20. Old library card number (if known)
21. I am reporting this to the library at
    I am reporting this to the library at

    I am reporting this to the library at
25. What do you need to do?*

    1. Report my library card lost or missing ($3 fee)
    2. I am turning in my library card and have no items currently checked out
    3. As a parent/guardian, I am revoking my child's library card and requesting it no longer be used
    4. My name has changed
27. Additional notes
29. Agreement Statements
    Please check the boxes next to each statement to signify your agreement, which will serve as your electronic signature. You must agree to both statements or a new library card will not be issued.
31. I understand that I am responsible for all items checked out on the missing card up to this written notice.*

    1. I agree.
32. I understand that if I do not get a replacement card at this time I will need to reapply in the future showing proper ID.*

    1. I agree.
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field