Application Form For Free Library Service - Adults

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New York State Talking Book and Braille Library
Application Form for Free Library Service: Adults
You can complete this form in Acrobat Reader, or, if you prefer, you can print the form
and fill it out entirely by hand.
Applicant Information (Please Print or Type)
For children under 18 years of age, please use the youth application form.
First Name:
Middle Initial:
Last Name:
Date of Birth:
Veteran. By law, preference in lending books and equipment is given to veterans.
Please check here if you have been honorably discharged from the U.S. armed forces.
E-Mail Address:
Name of local public library:
Contact Person. Please give the name and address of a contact person.
Contact Name:
Contact Address:
Contact Phone:
Contact E-Mail Address:
Eligibility for Library Service
Check the primary disability that prevents you from reading standard printed material:
Visual Impairment
Physical Disability
Reading Disability
(Must be certified by a Doctor of
Medicine or a Doctor of Osteopathy.)
Notice: Records relating to recipients of Library of Congress reading materials are confidential and
will not be disclosed without the consent of the individual. (New York State Civil Practice Law and
Rules, Section 4509, 1982, 1988).


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