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2. First Name*
3. Last Name*
5. Address 1*
7. Address 2
9. City*
10. State*
11. Zip*
13. Phone Number
14. Email Address
16. Is a friend or relative filling out this form for you?

    1. Yes
    2. No
18. If you are filling this out for a friend or relative, please enter your name and telephone number to validate this request.
20. Would you prefer large print books?

    1. Yes
    2. No
21. You may have up to 5 books, 2 movies and 2 audiobooks delivered each month. Is this the right amount for you?

    1. Yes
    2. No
23. If 5 books are too many, please choose the correct number.
    -- Select One --1234N/A
24. If 2 movies are too many, please choose the correct number.
    -- Select One --No Movies1 MovieN/A
26. If 2 audio books are too many, please choose the correct number.
    -- Select One --No Audio Books1 Audio BookN/A
27. The kind of story I enjoy most is:
    -- Select One --MysteriesRomanceAction / AdventureWesternsThrillersFantasyScience FictionHorrorSupernaturalHistorical FictionN/A
29. My second favorite kind of story is:
    -- Select One --MysteriesRomanceAction / AdventureWesternsThrillersFantasyScience FictionHorrorSupernaturalHistorical FictionN/A
30. My favorite non-fiction topic is:
    -- Select One --BiographiesHistory - USHistory - AncientHistory - EuropeHistory - WarTravelSportsScience & TechnologyTrue Detective StoriesReligionN/A
32. I have and can use a DVD player.*

    1. True
    2. False
33. I have and can use a CD player.*

    1. True
    2. False
35. Other topics or stories I enjoy are:
36. I have a home computer and can browse the Library's website to request the items I want delivered.*

    1. True
    2. False
38. Do you agree to pay all costs and fees assesssed by the Library for lost or damaged materials?*

    Overdue, lost or damaged books will result in loss of service and fees.

    1. Yes
    2. No
39. Please give us a name and phone number of someone we may contact for times you cannot answer your phone.
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

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