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.