Application

Name (First and Last):


Birthdate (MM-DD-YY):


Mailing Address:


Zip Code:


Telephone: Home Work

E-mail Address:


Residence Address:


Occupation:


Distance to Post Office:


Do you want books:

REQUEST ONLY? Check yes here is you want to receive library materials ONLY when you ask for a specific title, author, or subject. If you want REQUEST ONLY service, stop here and send us a list of requests. If you send a long list, we will send book shipments regularly until all requests are filled.
yes no

BY PROFILE?
Check yes here if you want to receive library materials automatically every 6-7 weeks. We will send your requests in addition to the titles we chose based on your profile. (Complete your profile below.)
yes no

We can send up to 20 books and 4 audiobooks (books on CD), movies (DVDs) and music (CDs) for a total of not more than 25 items. How many of each of these items would you like in each shipment? Please enter a quantity and then select the types of movies or music you prefer.

What percent of fiction (novels) or non-fiction (factual books) would you like?

Place the individual adult's number next to the type of books he/she would like to receive.

What percent of fiction (novels) or non-fiction (factual books) would you like?

Place the individual child's number next to the type of books he/she would like to receive.