Homebound Delivery

2. Contact Information
4. First and Last Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number*
13. Email Address
15. Do you currently have a Madison Heights Public Library card?*

    1. Yes
    2. No
17. Library Card Number

    If you already have a Madison Heights Public Library card, enter the full number here (no spaces).

19. Alternate Contact Information

    Please enter the contact information for an alternate person if the library is unable to contact you regarding your existing services. Providing this information will grant us permission to share information about your account with the person listed.

21. First and Last Name
23. Address
25. City
26. State
27. Zip Code
29. Phone Number
30. Email Address
32. Patron Preferences
34. Number of items desired per visit:

    Please enter a number between 1 and 100.

35. Preferred formats:

    Select all that apply.

    1. Standard Print
    2. Large Print
    3. Paperback
    4. Books on CD

    1. DVDs
    2. Blu-rays
    3. Music CDs
37. Reading Interests

    Please select all that apply.

39. Fiction

    1. Adventure
    2. Best Sellers
    3. Christian/Inspirational Fiction
    4. Classic Literature
    5. Contemporary Fiction
    6. Fantasy
    7. Historical Fiction

    1. Horror
    2. Mystery
    3. Romance
    4. Science Fiction
    5. Suspense
    6. Thriller
    7. Westerns
41. Non-fiction

    1. Adventure/Exploration
    2. Art/Architecture
    3. Biography
    4. Computers
    5. Cooking
    6. Diet and Exercise
    7. Finance/Investment
    8. Gardening
    9. Health
    10. History
    11. Hobbies
    12. Nature
    13. Paranormal

    1. Pets
    2. Philosophy
    3. Poetry
    4. Politics
    5. Popular Psychology
    6. Religion
    7. Science
    8. Self-help
    9. Social Issues
    10. Sports
    11. Travel
    12. Trivia
43. Reading Interests (cont.)

    Please specify any of the above reading interests. 

    Example: Travel, Europe; History, French Revolution

45. Favorite Authors and Books

    Please list your favorite authors and/or titles of books you have especially enjoyed.

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

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49. Submit

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