APPLICATION FOR TALKING BOOKS SERVICE

APPLICATION FOR TALKING BOOKS SERVICE NAME: _____________________________________________ ADDRESS: __________________________________________ CITY: ___________________________ ZIP CODE: _________ COUNTY: _______________________ PHONE: _____________ YEAR OF BIRTH: _________________ SEX: M: ____ F: ____ ARE YOU A VETERAN? YES ____ NO ____ CERTIFICATION: Please have a doctor, registered nurse, or other qualified person complete the following certification. Reading disability from organic/dysfunction must be certified by doctors of medicine or doctors of osteopathy. Reason applicant cannot use ordinary reading materials: (please check all that apply) ____ Legally Blind ____ Physically Handicapped ____ Visually Handicapped ____ Reading Disabled ____ Deposit Collection (Convalescent Facilities, libraries, etc.) CERTIFIED BY:_______________ TITLE: ___________________ ADDRESS: ___________________________________________ PHONE: _____________________________________________ BOOK SELECTION: I prefer to receive books in: ____ English ____ Spanish ____ French ____ Russian ____ Other ___________________________ I do not want to receive books that contain: (check all that apply) ____ Sex ____ Strong Language ___ Violence ___ Long Books Please mark the applicable statement: __ I wish to receive ONLY the books I select from the catalogs. __ I wish to receive books selected from my reading preferences. (See reverse side for the selection of preferences.) Rev. 8/03 READING PREFERENCES: (Please check all that apply) FICTION ___ Adventure ___ Humor ___ Short Stories ___ Bestsellers ___ Romance ___ War Stories ___ Historical Fiction ___ Mysteries ___ Westerns NON-FICTION ___ Autobiographies ___ Sports ___ Biographies ___ Travel ___ Biographies of Actresses/Actors ___ U.S. History ___ Religion ___ World History JUVENILE/YOUNG ADULT ___ Juvenile Fiction ___ Young Adult Fiction ___ Juvenile Non-Fiction ___ Young Adult Non-Fiction What Grade Level is your child or young adult?___________ A tape playing machine will be mailed to you, free of charge. You will be provided with large print catalogs. Recorded catalogs are available upon request. FOR MORE INFORMATION OR ASSISTANCE, CALL THE TALKING BOOKS SERVICE FROM 10:00 A.M. UNTIL 5:00 P.M., MONDAY THROUGH FRIDAY. GREATER WEST PALM BEACH: 561-649-5500 TOLL FREE: 1-888-780-5151

To return this application, fold so that the Library’s address shows on the outside. Tape or staple and mail. NO POSTAGE IS REQUIRED.

	FREE MATTER FOR THE BLIND AND PHYSICALLY HANDICAPPED
TALKING BOOKS LIBRARY PALM BEACH COUNTY LIBRARY SYSTEM-LIBRARY ANNEX 4639 LAKE WORTH ROAD, MIL-LAKE PLAZA LAKE WORTH, FL 33463-3451