Full Name: | |
| Street Address: | |
| City: | |
| Zip Code: | |
| Telephone (daytime): | |
| Telephone (evening): | |
| Date of Birth (mm-dd-yyyy) | |
| Gender: | Male Female |
| Please give the name of a person to contact if you cannot be reached for an extended period of time: | |
| Contact person's telephone: | |
| Indicate the primary reason you would need this service: | |
| | Other: |
| Do you have a home computer with internet access? | Yes No |
| Will you need Large Print materials? | Yes No |
| If yes, may we occasionally substitute regular print if Large Print is not available? | Yes No |
| Do you have a hearing impairment? | Yes No |
| If yes, is it moderate or profound? | Moderate Profound |
You may borrow either books or audio books. Do you prefer books, audio books, or both? | Book Audio Both |
| Material Preferences (Check all that apply): | |
| Adult Fiction: | |
| Adult Non-Fiction: | |
| Children's Fiction: | Early Juvenile Young Adult |
| Children's Non-Fiction: | Juvenile |
| Other categories: | |
| Check here if you wish to receive books in English language ONLY: | English Only |
| If you wish to receive books in other languages, please list: | |
| I do not wish to receive books that contain (check all that apply): | Strong Language Violence Explicit Descriptions of Sex |
| Do you have a library card? | Yes No |
| Please describe in detail how to locate your house, noting specific landmarks if possible: | |
| Is it within the city limits of Paducah? | Yes No |
| If your residence is in the county, what is the nearest main highway? | |
| CircEmail | |