Materials Request Form

Today's Date:

This form does not guarantee the library will purchase your request. All requests are reviewed by the library's collection manager. If your item is purchased, all holds will be placed in the order received. Thank you for your suggestion.

*Is the item you're requesting a: (Choose 1)

Please Select One... Book Book on CD Book on Cassette Large Type Book Music CD DVD Videocassette Magazine

*Title: *Author:

for DVD requests please fill in the actor/director boxes.

Actor: Director:

Please complete the following information:

*Your First name: *Your Last name:

*Burlington Library Card Number:

*Your Street address:

*City: *State: *Zip:

*Phone number: *E-mail address:

*Required information

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Request received by:

ISBN: Copyright date: Price:

Sources checked:

BPL Database

OCLC/WorldCat

SILO

Amazon

Barnes & Noble

Item Type:

Fiction Non-fiction

Item Format:

1. Hardback
2. Paperback
3. Non-print

Staff recommendation:

1. Purchase
2. Interlibrary Loan

Replacement copy(ies) Horizon Bib#

Request checked by:

Date Checked:

Date patron notified of status of request: