Print this form, fill it out, and bring it to the library.

	Request to Borrow (Rent) a
	Microfilm of a Newspaper
	or Other Publication
	Please print clearly
	Date: __________________________
	Your Name _______________________
	Your Phone #:________________________
	Address: ____________________________
	City/Zip:_____________________________
	If the name or address on yourlibrary card is different from the above information, or if you do not have a library card please tellsomeone at the circulation desk when you submit this request.
THERE MAY BE A $5.00 OR MORE CHARGE PER ROLL OF FILM. IF THERE IS A CHARGE, DO YOU AGREE TO PAY? YES _____ NO _____
	Roll # : ________________________
	Title: _____________________________
	Date: _____________________________
	Source where you found this information?
	____________________________________
	____________________________________
	For Staff Use Only:
	____________________________________
	____________________________________
	____________________________________
	____________________________________