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ARIZONA STATE BRAILLE
AND TALKING BOOK LIBRARY

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Fill out and then print the application below. If required, have it signed by a competent authority, as defined in the eligibility requirements.

Mail the form to:

 

Name

Address

City    ZIP+4 -

Home Phone   ( ) -

Work Phone   ( ) -

Age Group
14 yrs. and under    15-21 yrs.    22-30 yrs.    31-50 yrs.    over 50

I am registered with a state or private vocational rehabilitation agency for the blind.
Yes    No
If YES, please give organization:

I am enrolled in a public school special education program for the blind or state residential school for the blind.
Yes    No
If YES, please give organization:

I am registered with the Arizona Braille & Talking Book Library, a regional library of the National Library Service for the Blind & Physically Handicapped, Library of Congress.    Yes    No

If you answered no to all of the previous questions, have one of the following certify that you are blind or visually impaired and unable to read standard print.

a. Your doctor
b. Professional staff of hospitals or institutions
c. President of a local chapter or state affiliate of the National Federation of the Blind

 

I certify that the applicant named is unable to read or use standard printed material.

Name ________________________________________________ Date___________

Title and Occupation____________________________________________________

Address______________________________________________________________

Telephone (______) _____________________

Signature _________________________________________________________

MAIL THIS APPLICATION TO:

AZ Newsline
Braille & Talking Book Library
1030 N. 32nd Street
Phoenix, Arizona 85008
(602) 255-5578 Outside Phoenix area 1-800-255-5578

AZ NEWSLINE® is a cooperative effort of The Arizona State Library, Archives & Public Records, a division of the Secretary of State, and the Arizona Department of Economic Security, Rehabilitation Services Administration.

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