Books by Mail Service Registration Form

1. Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. How did you hear about us? *This question is required.

3. Name: *This question is required.

Last
First

4. Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Do you have a PWPL library card? *This question is required.

6. If yes, please provide your library card number.

6. Do you live in a senior living community? *This question is required.

7. If yes, which one?

Facility Name *This question is required.

Street Address *This question is required.

Apt/Suite/Office

Zip Code *This question is required.

Phone Number *This question is required. This question requires a valid number format.

Email Address This question requires a valid email address.

Name of Secondary Contact Person (family member, friend, or caregiver):

Name

Relationship

Phone Number This question requires a valid number format.

Email Address This question requires a valid email address.

Who will be the primary contact?

*This question is required.

Preferred Method of Communication:

*This question is required.

10.

Please briefly explain why you are requesting this service:

*This question is required.