Last Name First Name Date of Birth Street Address Apartment/Unit # City State Zip Code Phone Email Address Do you have a Des Moines Public Library card? Yes No Library Card Number ELIGIBILITY: Please indicate the primary disability preventing you from coming to the library to get materials. Check only one box. (Eligibilty must be confirmed by a certifying authority after submitting this form.) Blindness/visual impairment Physical disability BOOKS: Choose one of the following: Select books for me Do not select books for me Which formats do you prefer? Audiobooks on CD Regular print books Large print books List some of your favorite authors or book series. Do you have any special requests? What types of fiction do you enjoy? Children's Classics Fantasy Historical Fiction Humor Inspirational Fiction Mysteries Poetry Romance Science Fiction Short Stories Urban Fiction Westerns Young Adult What types of nonfiction do you enjoy? Biographies Business Computers Cookbooks Crafts Gardening Health and Fitness History House and Home Memoir Music Religion Self-Help Travel True Crime MUSIC: Choose one of the following: Select music for me Do not select music for me Which genres of music do you enjoy? Blues Classical Country Jazz Opera Pop Rap/Hip Hop Religious Rock Show Tunes Do you have any special music requests?