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Alaska Library Extension – Patron Profile
Name
First
Last
Year of Birth
Occupation
Mailing Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Residence Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Frequency of Mail
Distance to Nearest Library
Internet Access at Home
Reliability/Frequency
Home Phone
Work Phone
Email
Choose how you would like books selected for you:
I would like ONLY the books I request to be sent to me.
I would like books sent automatically according to the information in my personal preferences
I would like Electronic Services ONLY-These resources are available to all ALEX Patrons with internet service.
Adults in Household: Name, (birth year)
Adult 1
Adult 2
Adult 3
Adult 4
Children in Household: Name, (birth year)
Child A
Gender (Child A)
Select
Male
Female
Reading Level (Child A)
Child B
Gender (Child B)
Select
Male
Female
Reading Level (Child B)
Child C
Gender (Child C)
Select
Male
Female
Reading Level (Child C)
Child D
Gender (Child D)
Select
Male
Female
Reading Level (Child D)
Fiction
Place the individual's number/letter next to the type of books he/she would like to receive.
For the choices marked "specify", please include details in the space provided below genre choices.
Alaskana
Adventure
Best Sellers
Classics
Contemporary
Fantasy
Horror
Humor
Graphic Novels (Specify)
Historical
Mysteries
Religious
Romances
Science Fiction
Short Stories
Westerns
Audio
Videos
Non-Fiction
Place the individual's number/letter next to the type of books he/she would like to receive.
For the choices marked "specify", please include details in the space provided below genre choices.
Alaskana
Adventure
Art (Specify)
Art Technique
Biography
Best Sellers
Crafts (Specify)
Health
History
Hobbies (Specify)
How-To (Specify)
Humor
Nature
Poetry
Psych/Self-Help
Religious/Inspirational
Science
Sports
Travel
True Crime
Specify choices and preferences from the selections above.
Favorite Authors
Children's Favorite Authors
How many of each item would you like in each shipment (max of 25 total)? Audiobooks, Movies, Music (max 4 each)
Books
Audiobooks
Movies (VHS or DVD)
Music (CD)
What percentage should we send in each shipment?
% Fiction
% NonFiction
What percentage of the items are sent for...
% Adults
% Children
How did you hear about our program?
Please share additional information with us, including other hobbies and interests. It will help us select materials you enjoy.
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Email
This field is for validation purposes and should be left unchanged.
