Home Delivery Application

Name *

First

Last

Physical Address *

Mailing Address *

City *

State *

Zip Code *

Date of Birth (enter only numbers below) *

Library Card Holder

Gender

Phone Number (enter only numbers below) *

Library Card Number (if available)

Homebound Status *

Short Term (weeks/months) Long Term (years)

Reason for Status

example: surgery/transportation/disabled/agoraphobia

Additional Comments:

We the applicant and witness verify that the applicant is homebound and unable to physically get to the library at this time. By signing this application, we are giving the library director permission to call and verify the information we have hereby provided is accurate and true. By signing this application, we have received and read the home delivery policy and agree to abide by all the rules and regulations within.

Witness Name *

First

Last

Witness Phone Number (enter only numbers below) *

Witness Signature *

Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Applicants Signature *

Home Delivery Main Page

Home Delivery Registration

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