2. Section 1: Patron Information
4. First Name*
5. Last Name*
7. Library Card Number*
8. Phone*
10. Email*
12. Address
14. Address1*
16. Address2
18. City*
19. State*
20. Zip*
24. Section 2: Material Information
26. Title*
28. Author/Creator*
30. Format (check all that apply)*

    1. Book
    2. eBook

    1. Audiobook
    2. eAudiobook

    1. DVD/Blu-Ray
    2. Graphic Novel

    1. Magazine
    2. Other (please explain below)
32. Other
34. How did you become aware of this material?*

    1. Read/viewed it in full
    2. Reviewed portions
    3. Saw it online
    4. Heard about it from others
    5. Other (please explain below)
36. Other
40. Section 3: Nature of Your Concern*

    Please describe specifically what concerns you about the material. List page numbers, scenes, chapters, or passages.

44. Section 4: Context of Use*

    Who do you believe is the intended audience?

46. Have you discussed your concern with a Library staff member? (If yes, please include their name)*
48. What action are you requesting the Library take?*

    1. Reconsider placement
    2. Reevaluate age designation
    3. Remove the material
    4. Other (please explain below)
50. Other
54. Section 5: Supporting Information

    Are there reviews or resources you believe the Library should consider?

58. Section 6: Acknowledgement*

    1. I affirm that I am a Moorpark City Library cardholder, I have reviewed the material, I understand it remains available during review, and the City Librarian's decision is final.
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