ARIZONA TALKING BOOK LIBRARY

APPLICATION FOR ARIZONA RESIDENTS



Name (First, Middle Initial, Last)
   
Address
City

State
ZIP+4
-
  County
Phone  
( ) -
  Email
Date of Birth

Female Male
Alternate Contact
Relationship
Phone  
( ) -
Alternate Contact Email

Check here if honorably discharged from the Armed Forces of the United States.

ELIGIBILITY REQUIREMENT -- Check only one box
Blindness
Visual acuity of 20/200 or less with correcting lenses
Visual disabilityInability to read standard print with optical correction
Physical disabilityUnable to hold book, turn pages, or track words
Reading disabilityOrganic 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
Street Address
  City

State
ZIP+4
-
  Phone  
( ) -


Signature___________________________________________________________________________________________________


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


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