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: