Name of complaining party:_______________________________________

Name of organization you are representing:________________________

If a member of an organization, what is your title?_____________________________

Name/author of work for which reconsideration is requested:_____________________

______________________________________________________________________________

Copyright year and publisher of work at issue_____________________

Have you read or listened to the entire work?  Yes  No

If so, when did you read/listen to the work? (date)__________________

Please give page numbers of what you feel is offensive (please feel free to append

additional pages as needed):______________________________________________

____________________________________________________________________________

____________________________________________________________________________

Please give a brief summary entailing all salient characteristics in the work that

contravene the Selection Policy, and if there is some way in which the work could

be rendered appropriate (Please feel free to append additional pages as necessary):

_______________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I, the Undersigned, understand that failure to fill out this form in its entirety, placing

"N/A" where a particular line is not applicable, may forfeit reconsideration of this work.

Further, I understand that while my concerns are important to the Brownwood Public

Library, that this form in no way constitutes an obligation on the part of said Library to

implement the changes desired by me, the Undersigned.

___________________________         ________________

Signature                       Date