Materials Loan Request Form
Resource Center and Library
For Members of the
Brain Injury Association of Mississippi
P. O. Box 55912
Jackson, MS 39296-5912
(800) 641-6442 or (601) 981-1021
There is limit of three items at a time to be loaned out to any one person.
Materials borrowed from the library are due back in 30 days from the time they are received.
Each order for three or less items requires a $25.00 deposit in the form of a check made
payable to Brain Injury Association of Mississippi. This check will not be deposited and will be
returned to the borrower when the loaned items are received by the library by the due date.
Late fees of $1.00 per day will be deducted for each day loaned items are kept past the due
date.
Due to the popularity of some of these materials, the item you have requested may not be
currently available. We will make every effort to fill your request as soon as the item becomes
available.
I accept responsibility for the care of the materials while in my possession and agree to return
the materials to the BIA Library 30 days from the time I receive them. I also understand that late
fees of $1.00 per day will be deducted from the deposit for each day materials are late.
Name of borrower ( Please type or print)
_____________________________________________
Complete Mailing Address
_____________________________________________
_____________________________________________
_____________________________________________
Telephone: ( ______ ) ___________________________
Name of Item(s) Requested:
Book ___ Video ___ (1) ______________________________________________________
Book ___ Video ___ (2) ______________________________________________________
Book ___ Video ___ (3) ______________________________________________________
Please print this form locally, fill it in and mail with your remittance to: BIAofMS P.O. Box
55912 Jackson, MS 39296-5912
******************** FOR OFFICE USE ONLY ********************
Deposit __________Date Shipped __________ Shipped via __________ Returned
__________
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