Download a Home Library Service Application form ... - Libraries ACT
Download a Home Library Service Application form ... - Libraries ACT
Download a Home Library Service Application form ... - Libraries ACT
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Reasons for application (tick one)<br />
<br />
<br />
<br />
A short term illness, e.g. recuperating after an operation or suffering from a<br />
broken bone. Approximate time service will be required<br />
________________________________________________________<br />
Chronic or serious illness or disability that prevents me from visiting a library.<br />
Other (please specify) ______________________________________<br />
REFERRAL<br />
I nominate ______________________________ as a person requiring the<br />
services of the <strong>Home</strong> <strong>Library</strong> <strong>Service</strong> for reason/s listed above.<br />
Practitioner’s name<br />
______________________________________<br />
Organisation/occupation ______________________________________<br />
Address<br />
Suburb<br />
Phone (work)<br />
Email<br />
Signature<br />
______________________________________<br />
____________________ Postcode __________<br />
______________________________________<br />
______________________________________<br />
____________________ Date _____________<br />
<br />
<br />
Persons able to sign referral: Medical practitioner, activities officer (nursing homes),<br />
community nurse, community carer, Canberra Blind Society.<br />
A phone referral to 6207 5748 from one of the above is also acceptable.<br />
Please return <strong>form</strong>s to:<br />
MAIL<br />
<strong>Home</strong> <strong>Library</strong> <strong>Service</strong><br />
c/- Belconnen <strong>Library</strong><br />
12 Chandler Street<br />
Belconnen <strong>ACT</strong> 2617<br />
FAX<br />
6207 7400<br />
EMAIL<br />
(scanned completed <strong>form</strong>)<br />
library.customerinfo@act.gov.au
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