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
City
Zip Code
Phone
Email
Alternate Contact's Name
Alternate Contact's Phone
Date of Birth
 Male
 Female

Eligibility Criteria

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

Deliveries

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.)

Initials:

Profile

FICTION INTERESTS
 Best Sellers
 Award Winners
 Mystery
 Thrillers (Political/Spy)
 Thrillers (Legal)
 Thrillers (Medical)
 Adventure
 Fantasy
 Romance (Historical)
 Romance (Contemporary)
 Romance (Light)
 Family Saga (Contemporary)
 Family Saga (Historical)
 Classic Literature
 Historical Fiction
 Westerns
 Science Fiction
 Occult/Horror
 Short Stories
 Religious Themes
 Magazines (please specify below)
 Other Interests (please specify below)
NONFICTION INTERESTS
 Biographies
 Poetry
 Humor
 Current Events
 Travel
 Health Topics (please specify below)
 The Arts (please specify below)
 Crafts & Hobbies (please specify below)
 Other (please specify below)
MUSIC CDs
 Classical
 Show Tunes/Musicals
 Country/Western
 Christian/Gospel
 Popular (please specify below)
 Other (please specify below)
MOVIES (DVDs)
 Adventure
 Comedy
 Drama
 Horror
 Musicals
 Mystery/Suspense
 Science Fiction
 War
 Western
 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