Bethel Public Library

189 Greenwood Avenue, Bethel, CT 06801

203-794-8756   Fax 203-794-8761







Return this application to Bethel Public Library, ATTN: Home Delivery Service.


Please print or type:


DATE OF APPLICATION:                                                                                                                                                                


NAME: (LAST)                                                                                    (FIRST)                                                                  (INITIAL)             






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:                                                   




Applicant approved by Library Director                          Yes                          No                                                           Date received


Library Director’s signature                                                                                                                                                                              

Reason for denial                                                                                                                                                                                                




Endorsed by the Library Board of Directors                       May 18, 2015