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Sample Consent Form

In order to protect your privacy, we will need written permission specifying persons designated to access information in your record. The following may be printed and returned to the library to provide this consent, if desired:

I, _________________________________, give my permission for the following person(s):

___________________________________________

__________________________________________

to access information on my record.

Signature: ________________________________________

Date: _____________

Patron’s Library Card Number:________________________________________



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