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Individual Application for Talking Book and Large Print Library Services

• Application as PDF [32 KB] This file requires the free Adobe Reader.

Return this form to:
Maine State Library Outreach
64 SHS
Augusta, ME 04333-0064
1-800-762-7106

Free Library Service for Institutions

Please print and complete all pages of this application. Records relating to the use of library materials which contain names or other personally identifying details are confidential.

Application: Please print or type

Name (Last, Middle, First) _______________________________________________

Address ______________________________________________

City __________________________ State _______ Zip _______

Telephone ________________ Birth date ___________ Sex _____

Person to be contacted about your service if you can not be reached

Name ___________________________ Telephone ________________

Eligibility

Residency or U.S. Citizenship

Eligible readers must be residents of the United States, including the several states, territories, insular possessions, and the District of Columbia; or, American citizens domiciled abroad.

____ Veterans: By law, preference in lending of books and equipment is given to veterans. Check here if you have been honorably discharged from the U.S. Armed Forces.

Eligibility and Certification

Please check the primary reason that you are eligible to receive talking books.

____ Blindness [criteria 1]

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

____ Visual Impairment [criteria 1]

Persons whose visual disability, with correction and regardless of optical measurement, is certified by competent authority* as preventing the reading of standard printed material.

____ Physical Disability [criteria 1]

Persons certified by competent authority* as unable to read or unable to use standard printed material as a result of physical limitations.

____ Reading Disability [criteria 2 ]

Persons certified by competent authority** as having a reading disability resulting from organic dysfunction and of sufficient severity to prevent their reading printed material in a normal manner.

____ Deaf-Blind

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 hearing and understanding speech); ____ Profound (cannot hear or understand speech)

Criteria for Certifying Authority

1. *In cases of blindness, visual disability, or physical limitation, “competent authority” is defined to 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, case 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.
2. **In the case of reading disability from organic dysfunction, “competent authority” is defined as doctors of medicine and doctors of osteopathy who may consult with colleagues in associated disciplines.

To Be Completed By Certifying Authority

I certify that the applicant named has requested library services and is unable to read or use standard material for the reason indicated above.

Name ______________________________________________

Title/Occupation ______________________________________

Address ____________________________ Telephone _______

City _____________________ State ____ Zip Code __________

Signature __________________________ Date _____________

Reading Preferences

Reading Materials

What type(s) of reading materials do you want?

____ Books ____ Magazines ____ Descriptive Videos ____ *Scores, instruction or magazines about music

In what formats would you like to receive these materials?

____ Recorded cassettes ____ Large Print ____ Digital Cartridge ____ Braille**

*Materials about music provided form the National Library Service for the Blind and Physically Handicapped

** Braille Materials provided from the Perkins School for the Blind

Reading Equipment

Playback equipment and accessories 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 issuing agency.

Depending upon the formats specified above, we will lend you a standard cassette and/or digital cartridge player. If you require any other specialized equipment or accessories, please specify ____________________________________________

Frequency of Service

Most users are on a “return” system whereby each time they return a book we send another. Check here if you would like to receive books on this system: ____

How many books would you like to receive on this basis? ________________

Book Selection (check one)

____ The library may select books for me based on the reading preferences checked below.

____ Send only the specific titles I will request. Do not select books for me. (Note: You must borrow books regularly in order to remain active in the program and continue to use the equipment that has been loaned to you.)

Reading Content

Do you want: ____ Adult books ____ Young Adult Books ____ Children’s Books (grade _____)

Check if you do NOT wish to receive books that contain:

____ Strong language ____ Violence ____ Descriptions of Sex

In which languages do you want to receive books? ____ English ____ Spanish ____ French ____ Other (specify _____________________________)

Please indicate any other type of books or favorite authors that interest you. Be as specific as possible.

________________________________________________

Publications

If you apply for Talking Books, you will automatically receive the Talking Books Topics (bimonthly). Please check the reading format you prefer:

____ Large Print ____ Cassette ____ Computer disc

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