Request Form for Reconsideration of Materials

  • Himself/Herself
  • Other than himself/herself
  • If the Complainant is not yourself, give name of group &/or person, Address for Group &/or person, City, State, Zip code, and Phone number of group &/or person and Ext.
  • Source of Review(s) Date of Sources(s)
  • Author: Title: Publisher: Copy Right Date: ISBN: Review Source: Date: Page(s): Signature: Date: Received by: Staff Member Name: Date: