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* Title * First name * Last name * Address       Postcode * Telephone number Mobile number * Email address * Home library None selected Allestree Alvaston Blagreaves Chaddesden Central Local Studies Mickleover Pear Tree Sinfin Spondon   Please choose which library you want to collect your library card from We want to make sure that our library service is reaching all sections of the community. To help us find this out, please tell us which of these applies to you:   White 001 White British 002 Irish 003 Other White background Dual heritage 004 White and Black Caribbean 005 White and Black African 006 White and Asian 007 Other dual heritage  background Asian or Asian British 008 Indian 009 Pakistani 010 Bangladeshi 011 Other Asian background Black or Black British 012 Caribbean 013 African 014 Other Black background Chinese or other ethnic group 015 Chinese 016 Other ethnic background.    Please give details:   099 Declined to say Gender Male Female Do you consider yourself disabled?  Yes No * Date of birth  (dd/mm/yyyy) Do you qualify for any concessions? Yes No People in receipt of any of the following: Income support Working Families Tax Credit Incapacity Benefit Jobseekers Allowance People aged 60 and over Students Registered blind / visually impaired and other people who have difficulty with print Deaf or hearing impaired Data Protection: This form is not secure. Please don't include any confidential or sensitive information on it. We will treat any other personal information you provide in confidence and under the Data Protection Act 1998. We will hold it and only use it for a legal reason or for the purpose it is given. We will only share information when we have your consent or we need to ask another department or partner to respond to a specific comment or request you have made. We will keep a record of the sender's Internet Protocol address (which is unique to the sender's computer), the date we received the form, and the content for back-up and archive purposes. We will also use this record to identify senders of any malicious content under the Protection from Harassment Act 1997. We will keep this record for a maximum of three months. Please read our rules. Library rules I apply for membership of Derby City Libraries and agree to observe library rules. I accept responsibility for items borrowed on my library card.