Audio Bible Order Form
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Date: _________________
Applicant's Name:___________________________________________________
First Middle Last
Preferred title/name for mailing: ___________________________________________
Address: _______________________________________________________
Street
_______________________________________________________
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: _______________________________________________________
Street
_______________________________________________________
City, State and zip
Phone: _______________________________
Date: ________________________________
Certifying Authority's Signature: ________________________________________________
Please return this form to:
Orders
P.O. Box 621
Bradenton, FL 34206
