Purchase Request Form

Full Name (Last, First)*

Street Address

City

State

Country

E-mail*

Phone or Fax Number (include area code)*

Item Information

Material Type*

BookMagazine / NewspaperDVDBlu-RayCDE-bookOther

Age Level*

KidsTeensAdults

Title*

Author or Artist*

Publisher / Publication Date

I think the library should purchase this item because:*

If we purchase this item, would you like us to hold it for you?*

YesNo

Please provide library card number

If held, at which library?

Cedar Mill LibraryBethany Library

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