Hedberg@Home Facility Materials Delivery Application

Hedberg@Home Facility Materials Delivery Application

Facility Name ______________________________________ Phone ______________

Facility Name ______________________________________ Phone ______________

Address ________________________________________________________________ Street City State Zip

Address ________________________________________________________________ Street City State Zip

Resident Contact Person _________________________________________________

Resident Contact Person _________________________________________________

Address ________________________________________________________________ Street City State Zip

Address ________________________________________________________________ Street City State Zip

Email _________________________________________ Phone__________________

Email _________________________________________ Phone__________________

Conditions for Use 1. Facility agrees to provide adequate care and housing of materials. 2. Facility Accepts financial responsibility for all materials loaned by the library. 3. If the facility account is collected through a collection agency, costs levied by the collection agency shall be added. 4. The library assumes no liability for damage to equipment associated with the use of library materials. 5. Facility agrees to have materials ready for pick-up on the dates indicated. 6. No late fines will be assessed, but the facility will be held responsible for replacement costs for materials that are lost or damaged. 7. If the replacement costs total more than $50, the library may discontinue loaning materials to the facility until the balance is paid.

Conditions for Use 1. Facility agrees to provide adequate care and housing of materials. 2. Facility Accepts financial responsibility for all materials loaned by the library. 3. If the facility account is collected through a collection agency, costs levied by the collection agency shall be added. 4. The library assumes no liability for damage to equipment associated with the use of library materials. 5. Facility agrees to have materials ready for pick-up on the dates indicated. 6. No late fines will be assessed, but the facility will be held responsible for replacement costs for materials that are lost or damaged. 7. If the replacement costs total more than $50, the library may discontinue loaning materials to the facility until the balance is paid.

I understand and agree to the these conditions for use of library materials.

I understand and agree to the these conditions for use of library materials.

Facility Representative ____________________________ Title ________________

Facility Representative ____________________________ Title ________________

Email __________________________________________ Phone_________________

Email __________________________________________ Phone_________________

X_________________________________________________ Signature of Facility Representative

X_________________________________________________ Signature of Facility Representative

If you have any questions, please contact Maureen Birchfield at (608) 758-6592. Please fill out the back of this form to choose materials. 08/2013

If you have any questions, please contact Maureen Birchfield at (608) 758-6592. Please fill out the back of this form to choose materials. 08/2013

Material Selection

Material Selection

Type of material preferred and how many of each type. (Deliveries are made every five [5] weeks.)

Type of material preferred and how many of each type. (Deliveries are made every five [5] weeks.)

____ regular print hardcover ____ regular print paperback ____ large print

____ regular print hardcover ____ regular print paperback ____ large print

____ music CDs ____ DVDs ____ Blu-Ray ____ books on CD ____ magazines

____ music CDs ____ DVDs ____ Blu-Ray ____ books on CD ____ magazines

Fiction:

Fiction:

____ Best Sellers ____ Fiction ____ Westerns ____ Mysteries ____ Romance

____ Best Sellers ____ Fiction ____ Westerns ____ Mysteries ____ Romance

____ Historical Novels ____ Adventure ____ Sci - Fi

____ Historical Novels ____ Adventure ____ Sci - Fi

Non-Fiction:

Non-Fiction:

____ Art/Antiques ____ Health/Nutrition ____ Supernatural ____ Gardening

____ Art/Antiques ____ Health/Nutrition ____ Supernatural ____ Gardening

____ Cooking ____ Crafts ____ Sports ____ Travel ____ Biographies

____ Cooking ____ Crafts ____ Sports ____ Travel ____ Biographies

____ History ____ Crime ____ Inspiration/Religion ____ Humor

____ History ____ Crime ____ Inspiration/Religion ____ Humor

____ Other _________________________________________________

____ Other _________________________________________________

Music: (CDs only)

Music: (CDs only)

____ Popular _____ Soundtracks ____ Big Band ____ Jazz ____ Classical ____ Easy Listening ____ Spanish ____ Folk/Ethnic

____ Popular _____ Soundtracks ____ Big Band ____ Jazz ____ Classical ____ Easy Listening ____ Spanish ____ Folk/Ethnic

Favorite author(s) or performer(s)? _______________________________________

Favorite author(s) or performer(s)? _______________________________________

___________________________________________________________

___________________________________________________________

Deliver only items with NO: ____ strong language ____ sex ____ violence ____ horror

Deliver only items with NO: ____ strong language ____ sex ____ violence ____ horror

Other comments that would help us select appropriate material for you:

Other comments that would help us select appropriate material for you:

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Hedberg Public Library

316 S. Main St., Janesville, WI 53545 (608) 758-6600 www.hedbergpubliclibrary.org

Hedberg Public Library

316 S. Main St., Janesville, WI 53545 (608) 758-6600 www.hedbergpubliclibrary.org