APPLICATION/REGISTRATION FORM

Name: _____________________________________________________
Address: ___________________________________________________
City: _________________________ State: _______ Zip: ________________
Home Phone: (    )____________ Work Phone: (    )_____________________
E-mail address (optional): ________________________________________

I am registered with a state or private vocational rehabilitation agency for the blind. ___ Yes ___ No. If yes, please specify: _______________

I am enrolled in a public school special education program for the blind. ___Yes ___No. If yes, please specify: _______________

I am registered with a cooperating regional library under the program of The National Library Service for the Blind and Physically Handicapped, Library of Congress. ___ Yes __ No. If yes, please specify: ______________

If you answered no to all the above questions, you must include with this application a letter from one of the following certifying that you are blind, visually impaired, dyslexic or have a physical disability which prevents you from print reading. ___ Your doctor; ___ Social Security Award letter; ____ President of a local chapter or state affiliate of the National Federation of the Blind.

I would like to receive information in ____large print ____Braille or ____cassette format.

I certify that I am blind, visually impaired, dyslexic or have a physical disability and am unable to read a printed newspaper.

SIGNATURE _____________________________ DATE_____________

PLEASE RETURN THE COMPLETED FORM TO THE ABOVE ADDRESS