Application for Residential Services Name Street Address / P.O. Box Apt. Number Facility Room City Zip Code Birthdate Library Card # Phone Number Email Preferred method of communication - Select -Phone Email Notes in delivery bag Length of service requested - Select -Short TermLong Term Preferred Method of Delivery - Select -Books by MailMonthly 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 Submit
