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2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Email
14. Library Card Number
16. Are you representing an organization or a group?

    1. Yes
    2. No
17. If yes, please identify:
19. Material on which you are commenting:
    -- Select One --BookMagazineNewspaperAudiobookDVD
20. Title
21. Author/Producer
23. 1. What is your objection to this work? Please be specific; cite pages, sections, etc.
25. What do you feel might be the effect of reading/seeing/listening to this work?
27. For what age group would you recommend this work?
29. What do you feel is good about this work?
31. Have you read/seen/listened to the entire work? If not, which parts?
33. Have you checked reviews of the work?
35. What do you believe is the theme and purpose of the work?
37. What would you like the library to do about the work?
39. What, in your opinion, is a better work of this type that the library might consider adding to the collection?
41. Other comments
43. Submission of this form will be forwarded to the Library Director or an assigned designee who will take it to the Library Board. The Board will review the complaint at the next regularly scheduled meeting. The Board President, or representative, will notify the patron of the findings and action of the Board. Upon request, a patron requesting reconsideration of library materials will be given an opportunity to meet with the Library Board.
45. Signature
    Please type your name to sign this form.
46. Date
    Date
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

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