Home Delivery Service Application

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Home Delivery Service Application

Home Delivery Service Application

Contact Information

First Name *

Last Name *

Date of Birth *

Library Card Number

Address *

Apt./Room Number

City *

State *

ZIP Code *

Phone Number *

Email Address

Secondary Contact * Contact info of friend/relative for us to use in case we cannot reach you directly

Relationship *

Email Address

Phone Number *

Eligibility Criteria *

Chronic illness
No transportation
Physical disability
Visual impairment
Other

Please explain *

Special Instructions * Check ALL that apply to you

I read ONLY Large Print
I prefer Large Print but will accept Regular Print to fill my title requests
I read Regular Print
I can't hold heavy books
I want ONLY Audio Books

Please don't send book over the following amount of pages *

What formats do you prefer *

Large Print
Regular Print
Paperback Regular Print
Audiobook - CD
Audiobook - Playaway
Movie - DVD
Movie - Blu-ray
Music CD
Magazine

What genres do you prefer? *

Fiction
Nonfiction
Both

Fiction I am interested in... *

African American
Fantasy
Historical
Inspirational
LGBTQIA+
Literary
General Mystery
Cozy Mystery
Romance
Science Fiction
Thriller
Western
Woman's Fiction

Nonfiction I am interested in... *

Animals and Pets
Art
Biography
Business
Food
History
Humor
Journalism
Nature
Health
Poetry
Politics
Science
Sports
Self-Help
Spiritual Wisdom
Technology
Travel
True Adventure
True Crime

The kind of movie or TV show I am looking for... *

Action
Animation
Comedy
Drama
Experimental
Fantasy
Historical
Horror
Musicals
Romance
Science Fiction
Thriller
Westerns

Magazines I like to read...

Animals
Crafts
Food & Crafting
Home & Style
News
Pop Culture/Entertainment
Science
Sports
Woman's Fiction

Music I enjoy...

Blues
Classical
Country
Dance
Easy Listening
Folk
Hip-Hop/Rap
Holiday
Jazz
New Age
Opera
Pop
R&B/Soul
Reggae
Rock
Soundtrack
World
Other

Other music I enjoy

Things I want to avoid...

Addiction
Death
Disease
Explicit Sexual Content
Gore
Politics
Religion
Rough/Obscene Language
Sexual Themes
Violence
War

Please list some of your favorite books or authors:

Please list some books or authors you have read and NOT enjoyed

Indicate a setting about which you particularly like to read (country, state, time period, etc.)

Consent for storing submitted data *

Yes, I give permission to store and process my data

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Newark, OH 43055
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