Print the following application. Once you have completed it, drop it off at the library or mail it to Carteret County Public Library, 1702 Live Oak St., Suite 100, Beaufort, NC 28516.

REQUEST FOR HOMEBOUND SERVICE

Please print your name: ____________________________________________

Your mailing address: _____________________________________________

Your physical address if different than mailing:

________________________________________________________________

Your phone number: ______________________ Birth date: _________________

Please explain the circumstances that prevent your visiting the public libraries in Beaufort, Pine Knoll Shores, Cape Carteret or Newport:

[  ]     My own poor health or disability prevents me from leaving my house.

[  ]     Responsibility for another family member with poor health or disability requires my constant presence at home.

[  ]     There is no driver in the household. If this is the case, please state how and where you buy groceries, visit the doctor, and travel about.

          ____________________________________________________________

          ____________________________________________________________

 [  ]     Other: ______________________________________________________

           ____________________________________________________________

 Please tell us of any other services which you receive at your home, or which you receive because of being homebound or handicapped:

 [  ]     Meals on Wheels                            [   ] Visits from the Home Health Nurse

 [  ]     Other: _______________________________________________________

Reading Interests:

Select your reading interests from the following choices: 

Fiction Choices:

[ ]      Religious Fiction

[ ]      Romance

[ ]      Mysteries

[ ]      Suspense/Thrillers

[ ]      Westerns

Nonfiction Choices:

[ ]      Sports

[ ]      Travel

[ ]      History

[ ]      Animals

[ ]      Biography

[ ]      Self-Help

[ ]      Cookbooks

         Other:

         ______________________________

         ______________________________

         ______________________________

 Select the type of book you prefer:

 [ ]      Large Print

 [ ]      Regular Print

 [ ]      Paperbacks

 [ ]      Audiobooks:

          [ ]  audiobooks on cassette tape

          [ ]  audiobooks on compact disc

You may access the public library catalog by going to this website: www.cpclib.org

Thank you for sharing this information with us. If you have any questions, please call the Carteret County Public Library at 728-2050.

When we receive your form, we will contact you to discuss options for providing library materials to you on a regular basis.

Thank you.