National Federation of the Blind of Connecticut

NATIONAL NEWSLINE FOR THE BLIND NETWORK®

580 Burnside Avenue

East Hartford, Connecticut 06108

(860) 289-1971

APPLICATION/REGISTRATION FORM

Name_____________________________________________________

Address___________________________________________________

City_________________________State_______Zip________________

Home Phone ( )____________Work Phone ( )_________________

I am registered with a state or private vocational rehabilitation agency for the blind. p Yes p No. If yes, please specify_______________

I am enrolled in a public school special education program for the blind.

p Yes p 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. p Yes p 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 verifying that you are blind.

p Your doctor p Social Security Award letter p President of a local chapter or state affiliate of the National Federation of the Blind.

I certify that I am blind or visually impaired and unable to read a printed newspaper.

SIGNATURE_____________________________DATE_____________

OFFICE USE ONLY:

ID#__________SEC#_______DATE NUMBER GIVEN________