Birthday Book Club Form

Child's Surname

 Child's Given Name

Address

 apt.

City

 Postal Code

Tel #

 Child's Birth Date

Donated by: (Names to be included in book):

Tax receipt to:

Name

 Address

City

 Postal Code

Amount of donation:

 Book ($18.00) Method of payment: Cheque (Payable to
   Jewish Public Library)
  DVD ($18.00)   *Please note the processing will only begin upon receipt of payment.