Application for Homebound Services under Books By Mail

This application will qualify certified Maine residents for Books By Mail services based on homebound status. Homebound status is defined as a need to receive library materials by mail due to a physical inability to use local library services.

Please print out the application below, complete it and mail to:

Outreach Services
Maine State Library
64 State House Station
Augusta, Maine 04333

Application for Books by Mail Homebound Services

Please Print or Type

Birth date __________________

Last Name, First Name, Middle Initial


City State Zip County


Telephone (____) ______________

Please give the name and phone number of someone we can contact if you cannot be reached for an extended period:

Name _________________________________ Phone ___________________

Certification of Eligibility

Please have a doctor, nurse, social worker, counselor, teacher, librarian, or other qualified person complete this section.

Reason applicant cannot use ordinary reading materials:

_____ Permanent disability _____ Temporary disability

___________________________________ Cause_____________ Estimated date of recovery

Certified by:____________________ Title:_______________

Print or type Name:__________________________________