Name __________________________________
Street Address / P.O. Box ________________________________________________________
Apt. Number __________________________________
Facility ______________________________ Room __________________________
City __________________________________ Zip Code ______________________________
Birthdate __________________________________
Library Card Number ___________________________________________________________
Phone __________________________________ Email ________________________________
Check Your Choices
Preferred method of communication:
☐ Phone
☐ Mail
☐ Notes in delivery bag
Length of service requested
☐ Short Term
☐ Long term
Type of delivery requested:
☐ Books by Mail
☐ Monthly Door Drop
Emergency Contact Name __________________________________
I certify that I am unable to get to the library or bookmobile regularly and will notify staff if my circumstances change,
- ☐ Yes
- ☐ No
Contact Information for Person Completing Form if not the Member
Contact Name __________________________________
Relationship to Patron __________________________________
Contact Phone Number __________________________________
Contact Email __________________________________