Home → People with Disabilities → Homebound → Application for Homebound Services
Application for Homebound Services
This application will qualify certified Maine residents for Homebound Library 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 ServicesMaine State Library
64 State House Station
Augusta, Maine 04333
Application for Homebound Library Service
Please Print or Type
Birth date __________________
__________________________________________________
Last Name, First Name, Middle Initial
__________________________________________________
Street
__________________________________________________
City State Zip County
Email_____________________________________________
Telephone (____) ______________ Sex: M__ F__
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:__________________________________
Address:__________________________________________
_________________________________________________
Telephone____________
