Library of Congress
Acquisitions Fiscal and Support Office
Surplus Books Program
Application to Participate
rev. 5/30/2012
Updated Application
Renewal Application
New Application
Check one:
Organization Name:
Street Address
City: State: Zip:
Eligibility:
Full-time, tax-supported or nonprofit educational institution: school, school system, college, university, museum, or public library.
Government agency:
Nonprofit institution or organization that has tax-exempt status under the provisions of section 501 of the Internal Revenue Code of 1954 (see
41 CFR 101-44.207 (a)(17)) and that operates a library and/or research center open to the public.
IRS-issued tax identification number
Please indicate your qualification/s for eligibility and provide your tax identification number below.
Book Selectors:
List the individuals or Congressional office that will select books for your organization. Library of Congress staff members
may not select materials for Program participants.
First Name: Last Name:
Phone: Fax: Email:
Notify via email when new materials are available for selection.
First Name: Last Name:
Phone: Fax: Email:
Notify via email when new materials are available for selection.
First Name: Last Name:
Phone: Fax: Email:
Notify via email when new materials are available for selection.
My organization or institution will be responsible to make the arrangements for the shipping of materials selected
from the Surplus Books Program. This may include providing a Fed Ex or UPS account number, providing
Congressional frank labels, or hand-carrying the materials. If providing frank labels, my organization or institution
will make arrangements with a Congressional office to provide the labels.
Any knowing or fraudulent misrepresentations on this application may subject me to prosecution under federal law.
Certification:
No books will be shipped without a completed and approved application to participate.
Signature: Date:
Use an additional sheet if more space is needed.
Check each statement in acknowledgement.
Organization's Authorized Official Requesting Approval to Participate:
First Name: Last Name:
Job Title:
Phone: Fax: Email:
Notify via email when new materials are available for selection.
I understand that this application must be renewed every two years.
OFFICIAL USE ONLY:
I have verified the registration form is complete and I grant access to the Book Selector for the organization or institution listed above.
Signature: Date:
State Local Federal
