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First Name:
Last Name:
Middle Initial:
Street:
Apt:
City:
Zip:
Birthdate:
Is this address a senior residence, nursing home or assisted living? Yes
No
If yes, which one?
Telephone: ex. 952-000-0000
Email:
Are you unable to visit a library because of: Illness
Visual Impairment
Disability
Other 
How long do you need service: 2-6 months
Winter only
Ongoing
How do you prefer to receive materials: By Mail (postage is paid both ways)
By Volunteer
If volunteer, do you know someone who is willing to bring you materials?  Name
 Phone
Do you have a library card? Yes
No
Library Card Number:
What format of reading materials do you prefer?
(check as many as apply)
Large print
Regular print
Books on Compact Disc
DVD
To help us choose materials for you, please tell us some of your favorite authors, titles, or subjects:
How did you hear about At-Home Service? Friend
Relative
Hennepin County Library staff
Human services agency
Other
Please provide the following emergency contact information:
Name:
Relationship:
Phone:
Signature:
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