Home Delivery Service Application | Hicksville Public Library

Hicksville Public Library
169 Jerusalem Ave
Hicksville, NY 11801
Phone: (516) 931-1417
Fax: (516) 822-5672

Home Delivery Service form

First

Last

Date

Address

City/Town

ZIP/Postal Code

Phone Number

E-Mail

Library Card #

Name of secondary contact

Phone Number for secondary contact

I am a resident of the Hicksville School District who is unable to use the facilities because (check all that apply):

I have a physical disability

I am confined to home due to illness

Extended convalescence

Advanced Age

I do not have a household member to pick up library materials

For Temporary Application Only:

I am experiencing a short-term loss of mobility associated with surgery/illness and request this service for a finite period of time.

Favorite Authors and Titles

Favorite Authors and Titles
	Favorite Authors and Titles	Item weight

more items

Favorite Genres:

Romance

Mystery

Historical Fiction

Sci-Fi

Westerns

Non-Fiction

Other

Preferred Formats

Regular Print

Large Print

Paperback

DVD's

Playaways

E-Books

Magazines

CD Audio Books

Permission to access reading records

I give permission to the Hicksville Public Library to keep a record of the library materials sent to me in order to avoid duplication. This information is confidential.

Please enter any additional information here

Home Delivery Service form

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