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.