Title of book

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* 1. Title of book

Author

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* 2. Author

Format

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* 3. Format

Your full name

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* 4. Your full name

Library card number

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* 5. Library card number

At what email address would you like to be contacted?

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* 6. At what email address would you like to be contacted?

What is the street address where you currently live?

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* 7. What is the street address where you currently live?

What city do you currently live in?

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* 8. What city do you currently live in?

Looking at the work as a whole, what did you find unsuitable?

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* 9. Looking at the work as a whole, what did you find unsuitable?

Did you read or listen to the entire work?

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* 10. Did you read or listen to the entire work?

What action would you recommend be taken regarding the use of this material?

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* 11. What action would you recommend be taken regarding the use of this material?

Please initial that you agree with the answers as provided.

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* 12. Please initial that you agree with the answers as provided.

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