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JESSE WHITE • Secretary of State & State Librarian
Illinois State Library, Gwendolyn Brooks Building
300 S. Second St., Springfield, IL 62701-1796
READ FOR A LIFETIME
Final Reporting Form
Date: _________________________________________
School Name: ______________________________________ City: _______________________________
Read for a Lifetime Coordinator: _______________________ Title: ______________________________
Coordinators: The requested information for each student completing the program requirements of at least
four books from the list provided prior to the beginning of the school year MUST BE PRINTED OR TYPED. If
a student reads more than the required four, please list ALL additional titles. For additional space, you may
copy this form as needed. Please LIST FIRST and CIRCLE the name(s) of any senior(s) completing the program
for the fourth consecutive year.
In order to process the certificates and have them back to you in a timely manner, this form should be returned to
Jeanne Urbanek at the Illinois State Library by April 15. Address: 300 S. Second St., Springfield, IL 62701-
1796; Fax: 217-782-1877; Email: jurbanek@ilsos.net.
Please indicate the date you need to have your certificates in hand: ____________________________
Name
Grade Level
Book Titles
Printed by authority of the State of Illinois. September 2014 – 1 – LD A 224.2
Print
Save
E-mail
JESSE WHITE • Secretary of State & State Librarian
Illinois State Library, Gwendolyn Brooks Building
300 S. Second St., Springfield, IL 62701-1796
READ FOR A LIFETIME
Final Reporting Form
Date: _________________________________________
School Name: ______________________________________ City: _______________________________
Read for a Lifetime Coordinator: _______________________ Title: ______________________________
Coordinators: The requested information for each student completing the program requirements of at least
four books from the list provided prior to the beginning of the school year MUST BE PRINTED OR TYPED. If
a student reads more than the required four, please list ALL additional titles. For additional space, you may
copy this form as needed. Please LIST FIRST and CIRCLE the name(s) of any senior(s) completing the program
for the fourth consecutive year.
In order to process the certificates and have them back to you in a timely manner, this form should be returned to
Jeanne Urbanek at the Illinois State Library by April 15. Address: 300 S. Second St., Springfield, IL 62701-
1796; Fax: 217-782-1877; Email: jurbanek@ilsos.net.
Please indicate the date you need to have your certificates in hand: ____________________________
Name
Grade Level
Book Titles
Printed by authority of the State of Illinois. September 2014 – 1 – LD A 224.2
Name
Grade Level
Book Titles
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