Change of Service Form

Service

Change in service

Personal Information

Patron ID

Full Name

"In care of"

(if applicable)

Submitter Name

Name of the person submitting the request if different than the person listed above.

Submitter Relationship

Relationship of the submitter to the library user.

New Address

(Street or P.O. Box with Apartment/Room number)

Address

Address 2

City/Town

State

ZIP

Contact Information

Telephone with Area Code

Email address

Date

Effective date

Resume Service Date

If temporary, when would you like to change back to your permanent address?

Washington Talking Book & Braille Library