Application

Name (First and Last):

Date (MM-DD-YY):

Mailing Address:

City:

Zip Code:

Telephone:
Home Work
E-mail Address:

Residence Address:

Occupation:

Distance to Nearest Library:

Frequency of Mail:

Do you want books sent automatically based on the infomation in this profile? yes no

Do you want books by request only yes no

Do you want to request a pin number that will enable you to put holds on books and check the status of your account from your home computer?  yes no

Adults in household (Names):

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

Children in household (Names):

1.   Year of Birth 
2.   Year of Birth 
3.   Year of Birth 
4.   Year of Birth 

Place the child's number (from last step) next to the type of books he/she would like to receive:

Additional Comments: The more you tell us, the more likely we will pick books you will enjoy!