My Library

Mail-A-Book Service Application

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

 
1. Eligibility (Please mark any that apply. You must meet one of the following requirements to be eligible for Mail-A-Book Service.)
___ Physicial 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 yuo used above is seasonal)
5. City/Village/Township name: _____________________________
6. City ___  Village ___  Township ___ (Check one)
7. County: ______________________________________________
8. Phone: (    ) ______________(home) (    ) _________________ (other)
9. eMail: (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 changes to the above information.
11. Signature:
12. Parent/Guardian Name (if applicant is under the age of 18):
13. Parent/Guardian Signature: