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2. Date*
   Date
3. Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email address
14. Secondary contact information (i.e. spouse, relative, etc.):
16. Name of secondary contact
17. Phone of secondary contact
19. What Kind of Books Do You Like?*

    1. Adventure
    2. Biography
    3. Espionage
    4. Romance
    5. Nature

    1. Mystery
    2. Science Fiction
    3. Travel
    4. Westerns

    1. Classics
    2. Historical
    3. Self Help
    4. Other
20. If other, please specify.
22. What kind of books do you not want to receive?
24. Do you need large print?*

    1. Yes

    1. No
26. Are you interested in movies (DVD)?

    1. Yes

    1. No
28. Comments
30. Home Delivery Library Cards are kept at the Library at the main circulation desk.
32. Can you bring in your Library Card?

    1. Yes

    1. No
33. Do you need us to pick up your library card?

    1. Yes

    1. No
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

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