I, ____________________________________________________ apply in the name of

            (Name of Individual – please print)


____________________________________________________ to borrow audio-visual 

            (Name of Organization/Institution/Group - please print)


equipment from the Albemarle Regional Library System.  I agree to pick up and return the equipment to the library in Winton.


I agree that only knowledgeable persons will be allowed to operate this equipment, and my organization hereby takes responsibility for the payment of any damages associated with these items and/or overdue fines charged to this group. I understand that a deposit check in amount of the replacement cost must be left with the library prior to my checking out the equipment.  I understand that the equipment must be checked by library staff after its return.  If any repairs are needed, that cost will be deducted from the deposit check.  If the equipment is still in good condition, the check will be returned via the mail. 


Current overdue rate is $5.00 per day per item.



Signature: _________________________________________Date: _________________


Driver’s License #: ______________________Library Card #:_____________________


Home address: ___________________________________________________________


Home phone: ________________________  Business phone: ______________________


Organization/Institution/Group Address: _______________________________________



Equipment to be borrowed: _________________________________________________






Staff receiving reservation request: ___________________________________________


Date request forwarded to Regional Office: ____________________________________