2. Contact Information
4. First Name*
5. Middle Initial*
6. Last Name*
7. Date of Birth*
   Date of Birth
9. Address*
11. P.O. Box / Apt. Number
13. City*
14. State*
15. Zip*
17. Phone*
18. Email
19. Voting District
21. Alternate Contact Information
23. Address
25. P.O. Box / Apt. Number
27. City
28. State
29. Zip
31. Phone
32. Email
36. Employment Information
38. Employer
40. Address
42. P.O. Box / Apt. Number
44. City
45. State
46. Zip
50. Four Digit Pin Number*
    This will act like a password when accessing your account online.
51. Confirm Pin Number*
    Confirm your pin number by typing it in again.
52. Pick-up Location*
    -- Select One --WaynesboroStauntonFishervilleChurchvilleCraigsvilleDeerfield

    For reserved books.
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54. 1. Receive an email copy of this form.
55. Email address

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