Application for Extension Services Form

Application for Extension Services Form

If you are living in the City of Pembroke or the Township of Laurentian Valley and cannot visit the Library due to illness, injury or disability, you are eligible to have library materials delivered to your home or residence.
Applicant Name*

First NameLast Name
Address*

Street Address

Apartment/Room number

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email (optional)
example@example.com
Name of family member/friend who may be contacted if we are unable to reach you:*

NameRelationship
Phone Number*
Please enter a valid phone number.
I have read and agree to the terms of Pembroke Public Library's Extension Services Policy*

I agree
For Retirement Residence/ Assisted Living Centre Use Only:
Name of Residence or Centre:

Name
Address of Residence or Centre:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person between Library and Centre:

First NameLast Name
Contact Number:
Please enter a valid phone number.
Email:
example@example.com
Other notes (if applicable)
Please Read and Review the Extensions Services Policy:

https://pembrokelibrary.ca/wp-content/uploads/2023/09/OP-19.pdf
I have read and agree to the terms of Pembroke Public Library's Extension Services Policy*

I agree
Library Material Selection Form

Please tell us about your reading preferences.
Check off any of the following that are of interest to you:*

General FictionMysteryHorrorHistorical FictionFantasyNonfictionScience FictionSuspense/ThrillerRomanceWesternChristian/Inspirational FictionBiographies/MemoirsPlays/Poetry/EssaysGraphic NovelsYoung Adult & Children's Literature
Further notes regarding genre or subgenre preferences:
Favourite Authors: *
The Library has a collection of magazines. Please indicate the type (if any) that you would be interested in receiving:*

Food/CulinaryCelebrity NewsHealthLiterarySportsHuntingOutdoorsMen's topicsWomen's topicsSenior Citizen topicsHome DecorNews/PoliticsScience/TechnologyHistoryVisual ArtHandcrafts/SewingWoodworking/Handiwork
Please Indicate the type of Material you are interested in receiving each delivery:*

Large Print BooksRegular Print BooksAudiobooksDVDs/Blu-raysMusic CDsSoft Cover BooksMagazinesFrench MaterialsOther

Please Indicate the Quantity you are interested in receiving each delivery:*

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
Large Print Books
Regular Print Books
Audiobooks
DVDs/Blu-rays
Music CDS
Soft Cover Books
Magazines
French Materials

Other notes:
Should be Empty:

Application for Extension Services Form

For Retirement Residence/ Assisted Living Centre Use Only:

Library Material Selection Form