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 ……………………
Stamp size
Latest two photographs
Date of withdrawal of membership. ……………..
Amount Refund Rs. …………………..
Signature of Member ……………………………
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: -