Bethel
Public Library
189 Greenwood Avenue, Bethel, CT 06801
203-794-8756 Fax 203-794-8761
www.bethellibrary.org
APPLICATION FOR HOME DELIVERY OF LIBRARY MATERIALS
Return this application to Bethel Public Library, ATTN: Home Delivery Service.
Please print or type:
DATE OF APPLICATION:
NAME: (LAST) (FIRST) (INITIAL)
ADDRESS:
TELEPHONE: EMAIL:
Please provide contact information for someone we may call if you cannot be reached for an extended period.
NAME: TELEPHONE:
All recipients of home delivery of Bethel Library materials must be residents of Bethel. Recipients must not have anyone who can pick up or deliver materials to him/her on a regular basis and must meet one or more of the following requirements. Check all that apply:
Physical or mental disability that prevents me from coming to the Library on my own
Illness with minimum recovery period of 2 months
Non-driver age 65 or older
REFERRED BY:
Please specify reference: ex. Senior Center Director, Social Services Director, medical doctor, etc.
May not be a member of applicant’s family.
Overdue fines are not charged for materials delivered under this program; however, replacement costs will be charged for materials lost and/or damaged while in your care.
I agree to pay for library materials lost or damaged while in my care. I have received copies of the Home Delivery of Library Materials Policy, Procedures and Code of Conduct and agree to abide by them.
SIGNATURE: DATE:
FOR STAFF USE ONLY
Applicant approved by Library Director Yes No Date received
Library Director’s signature
Reason for denial