Future Reflections                                                                                                 Fall, 2003

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NFB-NEWSLINE Application Form

1800 Johnson Street, Baltimore, Maryland 21230

NAME: Last ____________________ First ________________ MI _______

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: _____________________________
______________________________________________________________

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

[  ] Teacher of the visually impaired/ O&M Instructor

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

SIGNATURE: ________________________________ DATE: ___________

PLEASE RETURN THE COMPLETED FORM TO THE ADDRESS ABOVE

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