Audio Bible Order Qualification Form

 Date: _________________ 

Applicant's Name:________________________________________________________
First Middle Last

 Preferred title/name for mailing: _______________________________________________ 

Address: ________________________________________________________________ 

________________________________________________________________________
City, State and zip  

Phone: _____________________________  E-mail: _____________________________ 

Nature of Impairment: _____________________________________________________

Please see eligibility requirements.

 Free Materials Requested: __________________________________________________

The following certification must be completed by a competent authority as recognized
by the National Library Service for the Blind and Physically Handicapped; such as
professional staff or agency or organization for the blind, a librarian, rehab worker, rehab
teacher, doctor, etc. 

Certifying Authority: ____________________________________________________

 Title: __________________ Organization/Agency:______________________________

 Organization Address: _____________________________________________________

 City, State and zip ________________________________________________________

 Phone: _____________________________  E-mail: _____________________________

 Certifying Authority's Signature:_____________________________________________

 Please return this form to:
Audio Bibles for the Blind • a division of Aurora Ministries •
P.O. Box 621 • Bradenton, FL 34206 USA