APPLICATION FOR LIBRARY SERVICE

Talking Book Library

Individuals

(Please print out or download this form as necessary)


Library registration and circulation records are confidential 
and protected under Florida State Statute (S257.261[15])

Please Print or Type:

Last Name: ___________________ First: __________________ Initial: ___

Street Address: ___________________________________________

City: _____________________________________________________

County: ___________________________________________________

State: ____________________________   Zip: ________________
 
Telephone: ________________________________________________

Date of Birth: ____________________________________________

Sex: ______________

May we have the name & number of a contact person in case we cannot reach
you? ____________________________________________________________________


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

Reading Preference:
 
Please check one of the following:

___ Send only the books I request. Do not select books for me.

___ I wish to have books selected for me. Have a reader advisor call me for an interview.

Language Preference:

___ Check here if you read English only, or list the language(s) in
which you are fluent, beginning with your native language:
__________________________________________________________


Books and Equipment:

You many borrow any of the following items.  Check those you wish to
receive. (Consult the enclosed Facts: Playback Machines and
Accessories Provided on Free Loan . . . for full descriptions.)

___ Talking books on tape and 

    ___ standard cassette player or
  
    ___ easy (E-1) cassette player
        (for those who cannot use a standard player)

___ Braille books

___ Magazines

    ___ cassette tape

    ___ braille

Accessories:

___ Headphones (For use where loudspeakers are not permitted)

___ Remote Control switch

___ Breath switch

___ Amplifier (For hearing impaired. Requires separate application) 

___ Pillowphone (For use by readers confined to bed)

___ Extension levers

Return of Equipment:

Playback equipment and special attachments are supplied to eligible persons
on extended loan. If this equipment is not being used in conjunction with 
recorded reading material provided by the Library of Congress and its 
cooperating libraries, it must be returned to the lending agency.  

Reason Why Applicant Cannot Use Standard Print Material:

Indicate the primary disability preventing you from reading standard print material.  
Check one:

___ Blindness                    ___ Deaf and Blind

___ Visual impairment            ___ Physical impairment

___ Reading Disability (Must be certified by a doctor of medicine or osteopathy.)

In addition to any of the conditions above, do you also have a hearing 
impairment?  If yes, indicate the degree of hearing loss.

___ Moderate. Some difficulty           ___ Profound. Cannot hear or
    hearing and understanding               understand speech.
    speech.
     
Eligibility Requirements:

The following persons are eligible for Talking Book Library service:

*   Blind persons whose visual acuity is 20/200 or less in the better eye
with correcting lenses, or widest diameter of visual field subtends an
angular distance no greater than 20 degrees.

*   Visually disabled persons whose disability, with correction,
prevents the reading of standard print material.

*   Physically disabled persons unable to read or use standard print
material as a result of physical limitations.

*   Persons having a reading disability, resulting from organic
dysfunction and of sufficient severity to prevent reading printed
material in a normal manner.

In cases of reading disability, certifying authority is defined as doctors of medicine 
or osteopathy.  In cases of blindness, visual disability, or physical limitations, 
certifying authorities can be doctors, ophthalmologists, optometrists, therapists, 
nurses, teachers, social workers, librarians, or other professionals whose competence 
is acceptable to the Library of Congress.  

To Be Completed by Certifying Authority:

I certify that the applicant named has requested library service and is unable to read 
or use standard print material for the reason indicated on page 2 of this form.  
(Please print or type.)

Name_____________________________________________  Date______________

Title or Occupation__________________________________________________

Address_____________________________________  Telephone______________

City, State, Zip Code: ______________________________________________

Signature: __________________________________________________________