NFB-NEWSLINE Subscription Form

I am registered with a state or private rehabilitation agency for the blind. *

If yes, please specify

I am enrolled in a public school special education program for the blind or state residential school for the blind. *

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, or unable to read newsprint due to a disability. *

I would like to receive information in the following format. *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Please enter your initials to certify that you are blind, visually impaired, dyslexic or have a physical disability and are unable to read a printed newspaper. *

Please enter the date to certify that you are blind, visually impaired, dyslexic or have a physical disability and are unable to read a printed newspaper. *

Month

Day

Year

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