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Eligibility Application
 for the Accessible Book Collection

 

Instructions

If you are a school or other non-profit organization that has a primary mission to provide specialized services relating to training, education, or adaptive reading or information access needs of blind or other persons with disabilities then this form should be filled out for each user who will have access to materials from the Accessible Book Collection. This form must be maintained at your facility so long as the user has access to materials from the Accessible Book Collection.

If you are an individual wishing to subscribe to the Accessible Book Collection this form must be completed and sent to the Accessible Book Collection by either mail or fax before your account can be activated. The address is 12847 Pt. Pleasant Dr., Fairfax, VA 22033. The fax # is (206) 600-7957.

User Information
Please Print

 

Name: Last ____________________________________________

First ______________________________ MI ______            

 

Street _______________________________________

City ____________________________State________ Zip _______

 

Phone ______________________ Occupation ______________________________

               

 

Certifier Information
Please Print

Certifier professional qualifications depend on the nature of the disability. If the reading disability is the result of a learning disability a qualified certifier could be a school learning disability specialist, school psychologist, clinical psychologist, doctor of medicine or osteopathy. 

In cases of blindness, visual handicap, or physical handicap, certification may be made by doctors of medicine or osteopathy, ophthalmologists, optometrists, registered nurses, therapists, professional staff of hospitals, institutions, and public or welfare agencies. In the absence of any of these a professional librarian may make the certification.

 

Name ________________________________________________________________

Title _____________________________

Street ________________________________________________

City __________________________State ________Zip _______

Phone ______________________ Occupation ______________________________

 

Indicate the nature of the disability that prevents the applicant reading standard print effectively.

____ Blindness / Visual Impairment
____ Learning Disability 
____ Other Physical Disability

I certify the existence of a physical basis of the visual, perceptual or other physical disability limiting the applicant’s ability to effectively use standard print, and that I have the professional qualifications to make such a certification.

 

Signature _______________________________________________________

Date ____________