PGTPL Request for Reconsideration
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Who do you represent?
*
yourself
an organization
Name of organization you represent?
What type of material or service are you commenting on?
*
Audiobook
Board Game
Book
Display/Exhibit
DVD/Blu-Ray
Library Program
Magazine/Newspaper
Music CD
Website
Other
What item/program/display/exhibit are you commenting on? (Please be specific)
*
How did this item/program/display/exhibit come to your attention?
*
Did you read or listen to the entire work, stay for the entire program, or view the entire display?
*
Yes
No
If you answered No, which selection or part did you hear, read, or view?
What is it that you find objectionable? (Please be specific; cite pages, scenes, or images, etc.)
*
Do you wish to be contacted by Library Administration regarding your concerns?
*
Yes
No
Other comments:
Submit
Should be Empty: