Public Library Information: To be completed by Edward M. Kennedy ...

Public Library Information: Public Library Name:________________________________________ Address:_______________________________________________________________ City:__________________________ State:____________ Zip Code:__________________

Contact Inform ation Name: ______________________________ Phone: _____________________________ E-mail: _______________________ Passes to be mailed: Y / N

Passed to be picked up: Y / N

Paym ent Method: Check (enclosed) ☐ Signature [print]:_____________________________________ Date:______________ Signature: __________________________________________ Date:______________

To be completed by Edward M. Kennedy Institute: Date of agreement received: ______________ Date of agreement approved:___________ Date of Payment Received: _______________ Program Start Date: _____________________ Program End Date: _______________ Passes Shipped on: ______________________ [disregard if Library to pick up passes] Signature [print]:_____________________________________ Date:______________ Signature: __________________________________________ Date:______________ E-mail: ______________________ Phone: ___________________________________ Columbia Point – 210 Morrissey Boulevard | Boston, Massachusetts 02125 | 617.740.7000