NEW YORK STATE TALKING BOOK BRAILLE LIBRARY CULTURAL EDUCATION CENTER ALBANY NY 12230-0001 (518) 474-5935 (800) 342-3688 tbbl@ mail. nysed. gov

APPLICATION FOR FREE LIBRARY SERVICE

For Individual Service at Home.      Please Print or Type.

Name: (Last)___________________________________ (First)_________________________ (Initial)___

Address: _______________________________________________________________________________

City: ________________________________ County: ___________________ State: ____ Zip: __________

Telephone: ____________________________ Date of Birth:__________________________ Sex:_______

Please give the name and address of a person we can contact concerning your current address if you cannot be reached. If the application is for a child under 18 years of age, a parent or guardian should complete the section below:

Name:__________________________________________ Relationship:___________________________

Address:_________________________________________________ Telephone:___________________

Veterans: By law, preference in lending books and equipment is given to veterans. Please check here if you have been honorably discharged from the armed forces of the United States.

CONFIDENTIALITY: Records relating to recipients of Library of Congress reading materials are confidential and, except to the extent necessary for the proper operation of the library service or where required by law,
will not be disclosed to any person or agency without the consent of the individual. (New York State Civil Practice Law and Rules, Section 4509, 1982/ 1988).

ELIGIBILITY FOR LIBRARY SERVICE

Indicate below the primary disability that prevents you from reading standard printed material:

__BLINDNESS. Visual acuity of 20/ 200 or less in the better eye with correcting lens, or the widest
diameter of visual field no greater than 20 degrees.

__VISUAL IMPAIRMENT. Inability to read standard printed materials without special aids other than regular glasses.

__PHYSICAL DISABILITY. Inability to read or use standard printed materials as a result of physical
limitations, e. g. paralysis, lack of arms or hands, extreme weakness, muscle deterioration.

__DEAF-BLINDNESS. Combination of legal blindness and profound hearing loss.

__READING DISABILITY. Organic (physical) dysfunction of sufficient severity to prevent reading printed material in a normal manner. (Must be certified by a doctor of medicine or a doctor of osteopathy who may consult with colleagues in associated disciplines.)

BOOKS AND EQUIPMENT

You will need the special players that we lend without charge to listen to our recorded books. WE WILL SEND A SPECIAL CASSETTE PLAYER TO EACH NEW BORROWER WHO WANTS RECORDED BOOKS. All our new recorded books are on cassette only.

MAGAZINES: More than seventy free magazines on recorded cassette and in braille are available as part of
this library program. Check this box if you would like to receive magazine information: __

MACHINE ACCESSORIES: Please check the appropriate box to indicate your accessory needs:

__Headphones for private listening only where loudspeakers cannot be used.

__Extension levers for the standard cassette player controls (for physically disabled borrowers only).

__Pillowphone for borrowers confined to bed.

__On-off remote control unit for those with serious physical and mobility difficulties.*

__Breath switch for remote control.*

__Amplifier for those with a significant hearing loss.*

(* We will send you a special application for these accessories)

READING INTERESTS & SERVICE PREFERENCES

You can choose how you get books. There are TWO basic service patterns. Whichever option you choose, you can order your own books, and these will get priority. Please read through this information carefully and check BOX 1 or BOX 2. below.

Other Reading Interests: ______________________________________________________________

__________________________________________________________________________________

IF WE CHOOSE BOOKS FOR YOU, WILL YOU ACCEPT:

We will send nothing unless you request it. We will send you catalogs to help you choose. You may also request books by author and/ or title. Remember, under this service option you will receive no books unless you
request them. Do not tell us your reading interests if you want this service.

BRAILLE BOOKS

In addition to recorded books, we have a large collection of braille books. If you want to receive
braille books, check the box here:

__"YES, I WOULD LIKE TO RECEIVE BRAILLE BOOKS."

FOREIGN LANGUAGE BOOKS

Some books are available in languages other than English. If you want books in another language, tell
us which language( s): __________________________________________

__Check here if you want books in this/ these language( s) ONLY.

The New York State Talking Book & Braille Library is a service of the NY State Library,
NY State Education Department, and the National Library Service for the Blind and Physically Handicapped, Library of Congress, Washington DC.

CERTIFYING THE APPLICATION

The application must be certified by an acceptable authority, as follows:

• BLINDNESS, VISUAL IMPAIRMENT, AND PHYSICAL DISABILITY: Acceptable certifying authorities include: doctors of medicine; doctors of osteopathy; ophthalmologists; optometrists; registered nurses; therapists; professional staff of hospitals, institutions, and public or welfare agencies (e. g. social workers, counselors, rehabilitation teachers, and superintendents). In the absence of any of these, certification may be made by professional librarians or by any person whose competence under specific circumstances is acceptable to the Library of Congress.
  
  
• READING DISABILITY: In cases where a reading or learning disability is the eligibility criterion, the certifying authority must be a doctor of medicine (MD) or doctor of osteopathy (DO), who may consult with colleagues in associated disciplines. This is required by law to certify not only that this disability exists and is severe enough to prevent the reading of standard print, but also that the identified condition has a physical basis.
  
  
• The application must bear the original signature of the certifying authority. The library cannot accept signatures that are photocopied, faxed, or rubber-stamped.
  
  
• Qualified borrowers must be residents of the United States, including the 50 states, territories, insular possessions, and the District of Columbia, or American citizens living abroad.

When the application has been completed and certified, please send it to the library at the address on page one. If all is in order we will then register you for this service and send you more information about the library. We look forward to serving you. Call 1-800-342-3688 if you have questions.