Future Reflections                                                                                          Spring, 2002

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NFB – NEWSLINE® Application/Registration Form

National Federation of the Blind
NFB – NEWSLINE® Service

1800 Johnson Street

Baltimore, Maryland 21230

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 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 and date: ________________________________________

OFFICE USE ONLY:

ID# ______________________SEC# ___________DATE ______________

                              Please return the completed form to the above address.

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