Request for Reconsideration of Library Material Form

About You

Request initiated by (Your Name)

Address (City, State, Zip)

Phone

Email

Who do you represent?

Yourself

Other

An Organization

Name of Organization

If other, please name:

About the Material

Title

Author

Publisher

This is a:

Book

Magazine

Audio

Movie

Other

1) To what in the work do you object (please be specific; cite page numbers):

2) Did you read/view/listen to the entire work?

Yes

No

If not, which parts have you read/viewed/listened to?

3) What do you feel might be the result of reading/viewing/listening to this work?

5) What do you believe is the theme of this work?

6) Are you aware of judgments of this work by literacy critics?

No

Yes

If yes, please indicate here:

7) What would you like the library to do about this work?