R. P. Flower Memorial Library
229 Washington Street, Watertown, New York 13601

Citizen's Request for Reconsideration of Library Material     (Please Print)

1. Request initiated by: ________________________________________________________________________________

2. Address: ________________________________________________________________________________________

3. City: ______________________State: __________Zip: ___________Phone:___________________________________

4. Complainant represents:
a. _____ him/herself
b. _____ organization (name) ___________________________________________________________________________
c. ______other (identify) ______________________________________________________________________________

5. Objection is to: ______ book ______ hardcover or ______ paperback ______ magazine
______ film ______ art ______ other (describe) ____________________________________________________________

6. Author: _________________________________________________________________________________________

7. Title: ___________________________________________________________________________________________

8. Publisher (if known) _____________________________ Date (if known) ______________________________________

9. Did you read the entire book? __________ What parts? ____________________________________________________

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10. Are you aware of the judgment of this book by literary critics? _______________________________________________

11. What do you believe is the theme of this book? ___________________________________________________________

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12. To what in the book do you object? (Please be specific; cite pages) ___________________________________________

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13. Is there anything good about the book? ________________________________________________________________

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14. What do you feel might be the result of reading this book? __________________________________________________

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15. For what age group would you recommend this book? ____________________________________________________

16. What would you like your library to do about this book?
        a. _____ do not lend it to my child
        b. _____ withdraw it from all readers as well as my child
        c. _____ send it back to the librarian for reevaluation

17. In its place, what book of equal literary quality would you recommend that would convey as
valuable a picture and perspective of the subject treated? _______________________________________________________

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18. Why did you select this book to read? __________________________________________________________________

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19. Would you select another book by the same author? _______ On the same subject?

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Signature of Complainant: _______________________________________________________________