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Home
Home Delivery Application
Home Delivery Application
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Physical Address
*
Mailing Address
*
City
*
State
*
Zip Code
*
Date of Birth (enter only numbers below)
*
Library Card Holder
Yes
No
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
*
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.
Submit
Home Delivery Main Page
Home Delivery Registration
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