Application for Home Delivery

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Email

Birthday

MM/DD/YYYY

Name

First Name

Last Name

Phone

Email

Which one of these best describes your situation?

I am primarily homebound and cannot travel to a Library location. I am temporarily homebound but expect to regain mobility?

When do you expect to regain mobility?

Do you have a Kitsap Regional Library card?

Yes No

Library Card Number*

Could you place holds in the online Library catalog if you were provided training?

Yes No

Which formats do you prefer? (check all that apply)

Regular print or large-print books Nonfiction or fiction Audiobooks on CD DVDs Magazines Music CDs

How many items can you finish in one month?

Tell us about books, movies and music CDs you love.

List the names of your favorite authors, actors, directors and musicians.