ContractMobile Library Service Agreement • April 28th, 2023
Main Contact Information Name: Address: Room Number: City: Postal Code: Phone: Email: Reason Mobile Library Service is Beneficial (Check one) □Mobility □Vision Loss □Injury □Health Condition □Transportation *Other Specify reason for "Other:" Duration of Service DD MM YYYY □Permanent □Temporary If temporary, delivery is required until: Payment for lost/damage materials:□ Bill to me□ Bill to my personal representativePersonal Representative Contact Information Name: Address: City: Postal Code: Phone: Email: Relationship:
