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Mobile Service Request Form - Recurring Visits

Name:*
Email:*
Phone number:	( ) - Second three digits Last four digits
Facility name:*
Address of facility:*
Type of facility:*	Apartment complex, community center, etc.
Audience served by facility:	Children, families, seniors
Estimated attendance:*
Which library is nearest to your site?:*
Does your facility have space for our bookmobile to park and service customers?:	Yes No The bookmobile is 27 feet long, 12 feet high and needs adequate space to maneuver. It also requires safe, legal, and accessible parking so customers can enter and exit the bookmobile.
What specific services or programs would you like us to provide?:*
Does your facility have a community room that we can use for occasional programming?:	Yes No
Do you have at least a 120V electrical outlet we can use for power? (Not a requirement):	Yes No
Additional requests: