(This form may be printed out and returned to the library)
Title of item __________________________________Book__Magazine__Other__
Author of item ________________________________
Request initiated by___________________________________________
Address__________________________________Phone_____________
City____________________________State_____Zip code___________
Do you represent
____Yourself
____An organization (name) ____________________________________
____Other group (name) _______________________________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
1. Did you read or view the entire work? __________What parts did you read or view?
2. To what in the work do you object? (Be specific; cite pages, sections etc.)
3. What do you believe is the theme of this work?
4. In your opinion, is there anything good about this work?
5. What do you feel might be the result of reading or viewing this work?
Signature_______________________________Date_________________________