GCPL Special Needs Mailbox Books Application

GWINNETT COUNTY PUBLIC LIBRARY
MAILBOX BOOKS Library Service for the Homebound

APPLICATION for SERVICE

Name: (Last, First, middle initial) * * denotes required field

Address: Street: * City: *
Zip: *

Telephone: (xxx-xxx-xxxx) * County: *
Email Address:

There is no charge to Gwinnett County residents. Out of county fees are $30.00/year.

Birth date: (mm/dd/yy) * Sex: Female Male (This information will be used for demographic statistics only.)

Do you already have a library card? No Yes, card #

To avoid duplication, it is necessary for the Library to keep a record of the materials sent to you.
Do you give permission for the Library to keep this record? Yes No

Statement of Eligibility - please select one:

I am homebound because of:

AGE, which is , or

CHRONIC ILLNESS, which is , or

VISUAL IMPAIRMENT, which is , or

PHYSICAL DISABILITY, which is , or

TEMPORARY CONDITION, which is , or

OTHER, (please state reason)

I will be responsible for any lost or damaged materials. I understand that past due accounts of over $25.00 will be referred to a collection agency and I will be charged an additional $10.00. I understand that a parent or legal guardian’s decision concerning checkout options available to minors is necessary to issue a library card to a minor before this service begins, and that staff will be happy to discuss the options with me.

Name: * Date: *

Parent/Guardian (for applicants under 18):

Important: Please complete the following Material Selection Information.

MATERIAL SELECTION INFORMATION

The library will send specific titles you request if they are available, or we will choose materials for you. If you wish to have materials selected for you, the library needs information about your interests. Please check the types of materials and subjects you prefer.

Please send me books: Large Print Standard print Books Paperbacks Magazines

Authors you like:

Preferred magazine titles:

Please send me audiovisual materials: Books on CD Books on cassette
Videos (limited selection, non-fiction) DVDs (nonfiction only)

How many items would you like in each shipment? *

Topic Selections - Check as many of these categories as you wish:

Qualified customers will be sent materials under the U.S. Postal Service’s “Free Matter for the Blind and Handicapped” program. The library pays the postage for other customers.

You may now print and mail this application to the following address,
OR simply click the SUBMIT button below to send your application in electronically.
For more information call 770-822-5366.

mail application to:
Mailbox Books
Gwinnett County Public Library
1001 Lawrenceville Highway
Lawrenceville, GA 30045-4707

OR

submit application electronically:

The Gwinnett County Public Library promotes accessible library services to all persons and does
not discriminate on the basis of race, religion, color, sex, age, national origin or disability.