STATE CENTRAL LIBRARY PANAJI - GOA Membership Application Form I Desire to become a member of Lending Section of the State Central Library/District Library/Taluka Library/Village Library. I have read the Rules and Regulations and agree to abide by them. I shall take proper care of the Library books and undertake to replace any book/s lost or damaged by me. I shall notify to the Library any change in my address. Full Name:- ........................ (In block letters beginning with Surname) Permanent Address:- .................... Present Address: - ...................... ..................... Phone No.: - ............. Age (for children's only):- ............ Profession/Designation:- ............... Two stamp size (3.5x2.5 cms.) latest photographs (for State/District/Taluka Libraries) and required deposit under Rule 5. Name and address of educational Institution/Office/ ............... Organization (for student and working people only) Nationality and passport No. .............. (for foreign nationals only) Specimen Signature ________________________________________________________________________ (FOR OFFICE USE) Reg. No. ............. Date of Reg. ............ Curator Receipt No. ......... Book No. ..... STATE CENTRAL LIBRARY Amount Deposited Rs. ........... Panaji - Goa Date of renewal of membership ........ Date of withdrawal of membership. ....... Amount Refund Rs. ......... Signature of Member ........... Stamp size Latest two photographs UNDERTAKING I ............................ .hereby agree to abide with the following conditions:- 1. That I shall return the Book within the specified time limit. 2. That care will be taken to see that the Book is handled properly/carefully and no danger is caused to the Books. 3. In the event of any damage caused to the Book issued to me, during the period, I undertake to pay cost of the Book to the Librarian/Government. Date:- ........... Signature of the Applicant NOMINATION I Dr./Shri /Smt. /Kum. /Mast./ ................................................................................ to hereby authorize/nominate .............................. (relationship) .............................. . who shall claim the refund of Library deposit on my behalf in the event of my death/Permanent Migration outside the State. Date:- Signature:- Place:- Name:- Witness:- 1) Name:- .................. Signature:- 2) Name: - .................... Signature: -
