Address __________________________________________________
City _____________________ State _______ Zip _____________
Home Phone ________________ Work Phone ________________
I am registered with the National Library Service for the Blind and Physically Handicapped, Library of Congress, also known as the “Talking Books” Program.
c Yes c No
I am enrolled in a public school special education program for the blind or a state residential school for the blind.
c Yes c No
I am registered with a state or private vocational rehabilitation agency for the blind.
c Yes c No
If you have answered No to all of the above questions, then you must include with this application a letter indicating blindness from your Doctor, the Social Security Admission, or your local chapter president of the National Federation of the Blind.
I certify I am blind or visually impaired and unable to read printed newspapers.
Signature: __________________________ Date __________________
Please Print this Form, complete the necessary information, and Mail to:
Sabrina Deaton, NFBF Registrar
1123 Meditation Loop