Homebound Delivery Form

Atwater Memorial Library Edward Smith Library
1720 Foxon Road 3 Old Post Road
North Branford, CT 06471 Northford, CT 06472
Application for Homebound Delivery Service
Name:
Address:
City/State/Zip:
Phone number:
Format: (000) 000-0000.
Email address:
example@example.com
EmailPhone
Disability that permanently prevents me from coming to the library on my ownDisability that temporarily prevents me from coming to the library on my ownDo not driveResident of a nursing facility
Contact person [optional]:
You may appoint someone to contact the library on your behalf and access your library information.
Name:
Phone:
Format: (000) 000-0000.
Please read and sign below:
I am applying for the homebound delivery service provided by the North Branford Public Libraries. I give permission for the staff of the North Branford Public Libraries to retain and use my library card to check out materials for me. I acknowledge that I am responsible for materials delivered to me through the Homebound Delivery Service. I am homebound and unable to visit the library due to health reasons and/or disability.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: