Homebound Delivery Application

Homebound Delivery Application

Fields in bold are required. If you have any questions about this application, please call (765) 641-2456.

First Name
Last Name
Street Address
Zip Code
Alternate Contact's Name
Alternate Contact's Phone
Date of Birth

Eligibility Criteria

Choose One:
 Physical disability
 Chronic illness
 Injury or convalescence (For how long? Please explain below)
 Other (Please explain below)


Choose only those that apply to you:
 I can only read large print books.
 I prefer large print books but will accept regular print books to fill my requests.
 Paperback editions are preferable.
 I prefer audiobooks when available.
 I prefer ONLY audiobooks.
 I am also interested in receiving other items such as movies or music.
I would prefer delivery...
 Once each month
 Twice each month
How many books or other items would you like to receive in each delivery?

I understand that I assume full financial responsibility for the materials I receive. If any materials are lost or damaged, I agree to pay the library the cost of replacing them. (By entering your initials in the box below, you indicate your agreement with this statement.)



 Best Sellers
 Award Winners
 Thrillers (Political/Spy)
 Thrillers (Legal)
 Thrillers (Medical)
 Romance (Historical)
 Romance (Contemporary)
 Romance (Light)
 Family Saga (Contemporary)
 Family Saga (Historical)
 Classic Literature
 Historical Fiction
 Science Fiction
 Short Stories
 Religious Themes
 Magazines (please specify below)
 Other Interests (please specify below)
 Current Events
 Health Topics (please specify below)
 The Arts (please specify below)
 Crafts & Hobbies (please specify below)
 Other (please specify below)
 Show Tunes/Musicals
 Popular (please specify below)
 Other (please specify below)
 Science Fiction
 Other (please specify below)
Please list a few of your favorite authors or any other information that may assist us in selecting materials for you.

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move