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Member# 12345, Card Number*
MEMBER PERSONAL DETAILS * F M     Date of Birth (dd/mm/yy)
Title Initials Given Names* Surname* Prefered Name
 
Ethnicity Ethnicity Notes Membership Category*
 
MEMBER ADDRESS
Postal Address* Town* Area
 
Street Address if different Town
 
MEMBER CONTACT DETAILS
Phone (Home) Phone (day) Fax Email
 
ALTERNATE CONTACT DETAILS
Name* Phone Relationship*
 
Notes
 
LIBRARY USE
Notes
 
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