Mailbox Books Library Service for The Homebound - Application for Service
Email address *
Mailbox Books service is available to Gwinnett County residents.
Do you already have a library card? *
Library card number (if you have one)
Your answer
Date *
MM
/
DD
/
YYYY
Name (First, Middle Initial, Last) *
Your answer
Telephone Number *
Your answer
Street Address *
Your answer
City *
Your answer
County *
Your answer
Zip Code *
Your answer
Email Address
Your answer
Birth Date *
Your answer
Gender (this information will be used for demographic statistics only)
To avoid duplication of materials, it is necessary for the Library to keep a record of the materials send to you. Do you give permission for the Library to keep this record? *
Statement of Eligibility
I am homebound because of (please select one): *
If other: please state reason
Your answer
I will be responsible for any lost or damaged materials. I understand that past due accounts over $25.00 will be referred to a collection agency and I will be charged an additional $10.00.
To accept, type name and date below. For applicants under 18 years of age, include parent/guardian name. *
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Gwinnett County Public Library. Report Abuse - Terms of Service