MORE REIMBURSEMENT TO OTHER MORE LIBRARY
COLLECTED AT (LIBRARY) : ______
SENT TO (LIBRARY) : ______
FROM (PATRON NAME) : ______
(PATRON BARCODE) : ______
Reimbursement for: (circle one)
(a) Item (b) Item part (c) Collection Agency fee (d) Pre-MORE fines
For (a) or (b):
Item barcode: ______Title: ______
Format : (circle one) Book DVD Video Audiobook CD or Cass
Other______
Reimbursement Amount: ______
______
Signature of Authorized Staff Member Date
MORE REIMBURSEMENT TO OTHER MORE LIBRARY
COLLECTED AT (LIBRARY) : ______
SENT TO (LIBRARY) : ______
FROM (PATRON NAME) : ______
(PATRON BARCODE) : ______
Reimbursement for: (circle one)
(a) Item (b) Item part (c) Collection Agency fee (d) Pre-MORE fines
For (a) or (b):
Item barcode: ______Title: ______
Format ; (circle one) Book DVD Video Audiobook CD or Cass
Other______
Reimbursement Amount: ______
______
Signature of Authorized Staff Member Date