ARIZONA TALKING BOOK LIBRARY

APPLICATION FOR ARIZONA RESIDENTS    Honorably discharged from the Armed Forces of the United States.

(First, Middle Initial, Last)
Address
City
State
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  County
Phone
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   Email
Date of Birth
Female Male
Alternate Contact
Relationship
Phone
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   Alternate Contact Email

ELIGIBILITY REQUIREMENT -- Check only one box
Blindness -- Visual acuity of 20/200 or less with correcting lenses Physical disability -- Unable to hold book, turn pages, or track words
Visual disability -- Inability to read standard print with optical correction Reading disability -- Organic dysfunction causing inability to read standard print

Certification signature required. Certifier cannot be a relative or the applicant.
In cases of blindness, visual and/or physical disabilities, the following persons may certify:
M.D., D.O., R.N., Ophthalmologist, Optometrist, therapist, and professional staff of hospitals, institutions, libraries, schools and public or private welfare agencies.
In the case of a Reading Disability, a M.D. or D.O. must certify this application.


I certify the applicant is unable to read or use standard printed material for the reason indicated above.
(MUST INCLUDE SIGNATURE OR STAMP OF CERTIFYING AUTHORITY TO BE PROCESSED.)


Name (First, Middle Initial, Last)
Date
Title and Occupation
Address
City
   
State
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  Phone
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Signature___________________________________________________________________________________________________


Mail, fax or email application to:
Arizona Talking Book Library
1030 N. 32nd Street
Phoenix, Arizona 85008
Fax: 602-286-0444
Email: [email protected]
Phone: 602-255-5578
www.azlibrary.gov/talkingbooks


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