Name Mailing Address City, State, Zip Physical Address (if different) Home Phone (so library staff can contact you) Best day and time to call you E-mail Gender male female Birth date Do you reside in a residential care facility or an apartment complex? yes no If "yes," facility name Name of person helping fill out this form Should library staff contact the person helping to fill out this form about applicant's reading preferences? yes no If yes, phone number
