Inter-Library Loan Form

Contact Information
If our policy calls for passing on charges, how much are you willing to pay?
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
  _____    __   _  __   ___    _____    _   _ 
| __ \ /_ | | |/ / / _ \ | __ \ | \ | |
| |__) | | | | ' / | (_) | | |__) | | \| |
| ___/ | | | < \__, | | ___/ | . ` |
| | | | | . \ / / | | | |\ |
|_| |_| |_|\_\ /_/ |_| |_| \_|

Enter the code depicted in ASCII art style.