* Indicates a required field

1. Please print the name of the individual as it should appear on the bookplate:*
 

2. Please print your donor's name or organization as it should appear on the bookplate:*
 

3. Please indicate the location of the gift's placement:*
Central Library, 320 Washington Avenue, Elyria West River Branch, 1194 West River Rd. N., Elyria North Branch Library, 1005 N. Abbe Rd., Elyria South Branch Library, 1215 Middle Avenue, Elyria Keystone-LaGrange Library, 301 Liberty St., LaGrange Bookmobile, 1194 West River Rd. N., Elyria  

4. Please indicate area of interest, hobby, etc.*


5. Please print the name & address of the person to be notifed of your gift.*
Name:  
Address:  
City:    State:    ZIP:  

6. Indicate type of contribution below:*
Children's Book Teen's Book Adult Book Music & Movies  

7. Please check the gift occasion:*
Memorial Birthday Graduation Anniversary Thank You Wedding Other  

Notes or comments:


Name and Address of Donor*

Name:  
Address:  
City:    State:    ZIP:  
Phone:  
Email:    

Only needed if paying by check.
Check Number: