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

ZIP+4
-

County

Phone ( ) -		Email
Date of Birth	Female Male

Alternate Contact

Relationship

Phone
( ) -

Alternate Contact Email

ELIGIBILITY REQUIREMENT -- Check only one box

Blindness -- Visual acuity of 20/200 or less with correcting lenses	Physical disability causing inability to read or use regular printed material
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	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: [email protected] Phone: 602-255-5578 www.azlibrary.gov/talkingbooks
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