Newsline Application

National Federation of the Blind
National Newsline for the Blind Network
1800 Johnson Street
Baltimore, Maryland 21230

APPLICATION/REGISTRATION FORM

NAME:________________________________________________________________
ADDRESS:_____________________________________________________________
CITY: ______________________________ STATE____________ ZIP_____________
HOME PHONE: ( ) _________________ WORK PHONE: ( )__________________

I am registered with a state or private vocational rehabilitation agency for the blind.

Yes: ____
No: ____

If Yes, please give name below:
_______________________________________________________________________

I am enrolled in a public school special education program for the blind or a state residential school for the blind.

Yes: ____
No: ____

If Yes, please specify: _____________________________________________________

I am registered with a cooperating regional library under the program of the National Library Service for the Blind and Physically Handicapped, Library of Congress.

Yes: ____
No: ____

If Yes, please specify: _____________________________________________________

If you answered "NO" to all the above questions, you must include with this application a letter from one of the following certifying that you are blind.

Your doctor: ____
Social Security Award Letter: ____
President of a local chapter or state affiliate of the National Federation of the Blind: ____

I certify that I am blind or visually impaired and unable to read a printed newspaper.

SIGNATURE: ________________________________________ DATE: ____________

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OFFICE USE ONLY:

ID#____________ SEC# ____________ DATE NUMBERS GIVEN ________________

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PLEASE RETURN THE COMPLETED FORM TO THE ABOVE ADDRESS

For questions about this information, contact Shiela A. Pollock (608) 224-5395

Last updated on 2/28/2008 8:53:23 AM