Mail-A-Book Library Card Application

Send to: NWLS / 3200 E. Lake Shore Dr. / Ashland, WI 54806

1. Eligibility (Please mark any that apply to you. You must meet one of the following requirements to be eligible for Mail-A-Book Service.)

____Physical limitation ( ____long term or ____temporary)

____Homebound/lack of transportation ( ____long term or ____temporary)

____Residence is 15 miles or more from the nearest public library

2. Name: (Last, First, Middle Initial)

3. Local address: (Address, City, State, ZIP Code)

4. Alternate address (if the address you used above is seasonal):

5. City/Village/Township name:

6. City___ Village___ Township___ (check one)

7. County:

8. Telephone: (   ) _______________(home)     (   )_______________(other)

9. E-mail: (Please print clearly.)

10. Birth date:

I accept responsibility for all materials borrowed on my card.
I agree to give immediate notice of card loss or of a change of name or address.

11. Signature:

12. Parent/Guardian name (if applicant under the age of 18):

13. Parent/Guardian signature :