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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip
13. Email*
14. Phone Number*
16. Type*

    1. Student (12 and under)
    2. Adult
17. Online Passcode

    Your Online Passcode will be the last four digits of your phone number unless you provide a different four digit number above.

19. Disclaimer

    By hitting submit, I agree to obey all the rules and regulations of the Pleasant Hill Public Library, to promptly pay all fines and other charges against me for the injury or loss of books and other items, and to give immediate notice of any change of address.

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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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