ARIZONA TALKING BOOK LIBRARY

APPLICATION for INSTITUTIONAL SERVICE
Demonstration Purposes Only



Agency Name
 Contact Person
Address
 City
State

 ZIP+4
-
Telephone Number  
( ) - 		Extension
Contact's Email
Type of Agency

 If Other, please describe:
Types of Service Requested
Digital Player -- Maximum: one (1) of each model
Advanced Model (DA1)
Standard Model (DS1)
BARD (Braille and Audio Reading Download) Access

Reader Profile - Check what applies to those who will be using the service
Books should be in:
If other, please describe:
Restrictions: (Please Select)
No explicit descriptions of violence
No explicit descriptions of sex
No strong language 		Reading Level: (Please select)
Juvenile (Check all that apply) P-3   2-6   4-7   5-9
Young Adult
Adult

Authorization Signature
I certify that this agency regularly provides service to individuals who are unable to read a regular print book because of a permanent or temporary visual or physical disability. I hereby request an institutional account with the Arizona State Braille and Talking Book Library in order to provide these individuals with the opportunity to enjoy recorded materials.
   

ADMINISTRATOR'S Signature
(Other than contact person)

___________________________________


Date

___________________________________


Printed Name

___________________________________


Title

___________________________________

Phone

___________________________________

XT

___________________________________


Administrator's Email: __________________________________________________________________________________________________________

Mail completed application to:

Arizona Talking Book Library
1030 N. 32nd Street
Phoenix, Arizona 85008
Attn: Michael Usrey
[email protected]

For more information about the library visit the website at
www.azlibrary.gov/talkingbooks

Arizona State Library, a Division of the Secretary of State