Application for Residential Services Name Phone Number Street Address / P.O. Box Apt. Number Facility Room City Zip Code Birthdate Gender - Select -Female Male Email Library Card # Drivers License or State/Federal ID number Best Time to Contact Preferred method of communication - Select -Phone Email Notes in delivery bag What makes it difficult for you to get to the library or Bookmobile? Is the limitation: - Select -Permanent Temporary Emergency Contact Information Name (emergency contact) Contact Information for Person Completing Form if not the Member Relationship Phone Number Signature Date Name (not member) Or verbal consent given to Phone Number Additional Question for No Contact Door Drop Delivery Where should the delivery bag be dropped off/picked up? Submit
