APPLICATION

I AM UNABLE TO READ CONVENTIONAL PRINT MATERIALS DUE TO:
     BLINDNESS________   VISUAL IMPAIRMENT___________
     OTHER PHYSICAL DISABILITY____________

DO YOU WISH TO BE CONTACTED BY A REHABILITATION TEACHER?
     YES_______NO________

ARE YOU PHYSICALLY ABLE TO TURN ON A RADIO?  YES_____ NO_____

ARE YOU REGISTERED FOR THE LIBRARY OF CONGRESS TALKING BOOK
PROGRAM?  YES________    NO__________
     (IF YOU USE THE TALKING BOOK SERVICE, YOU MAY PROCEED  TO PART
THREE WITHOUT A PHYSICIAN'S SIGNATURE)

* * * * * * * * * * *
VISUAL/PHYSICAL DISABILITY- TO BE COMPLETED BY A COMPETENT HEALTH
CARE AUTHORITY, E.G. PHYSICIAN, NURSE, SOCIAL WORKER, OR
REHABILITATION COUNSELOR.

THIS IS TO CERTIFY THAT_______________________________________________
                              (APPLICANT'S NAME)
IS UNABLE TO READ CONVENTIONAL PRINT MATERIALS DUE TO:
______________________________________________________________________________
______________________________________________________________________________

CERTIFIED BY:       ________________________________________________
                         (SIGNATURE OF PHYSICIAN OR OTHER
                           HEALTH CARE AUTHORITY)

                    _________________________________________________
                         (PRINT OR TYPE NAME)

           ADDRESS:  _________________________________________________

           PHONE #:  _____________________DATE:__________________

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