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Arizona State Library, Archives and Public Records, a division of the Secretary of State

Home > Braille and Talking Book Library > How To Apply > Individual Application for Service

ARIZONA STATE BRAILLE
AND TALKING BOOK LIBRARY

APPLICATION FOR ARIZONA RESIDENTS

Mr./Mrs./Ms.
Address	City
State	ZIP+4 -
Telephone Number ( ) -	Message Telephone ( ) -
Date of Birth	Female Male
By Law, preference in lending books and equipment is given to veterans. Please check here if you have been honorable discharged from the armed forces of the United States.
INDICATE THE DISABILITY PREVENTING THE USE OF STANDARD PRINTED MATERIAL (see definitions under eligibility criteria):
Visual disability Blindness	Physical disability Reading disability (See eligibility criteria No.4)
BRIEF DESCRIPTION OF VISUAL OR PHYSICAL DISABILITY: (MUST BE COMPLETED BEFORE APPLICATION IS ACCEPTED.)
TO BE COMPLETED BY CERTIFYING AUTHORITY:
I certify that the applicant named has requested library service and is unable to read or use standard printed material for the reason indicated above.
Name ___________________________________	Date ___________________________________
Title and Occupation ___________________________________
Street Address ___________________________________	Telephone ___________________________________
City, State, ZIP ___________________________________	Signature ___________________________________
Mail the completed application and certification from to: Arizona State Braille And Talking Book Library 1030 N. 32nd Street Phoenix, Arizona 85008
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Updated: 05/23/2007