Newsline: Application

Newsline for the Blind of Michigan
2809 Lapeer Road
Flint, Michigan 48503
Telephone: (810) 233-4776


Name______________________________________________

Address______________________________________________

City____________________ State_________ Zip____________

Home Phone (_____)_______________ 

Work Phone (_____)_______________

I currently borrow Braille or Talking Books from a Michigan Library for the Blind and Physically Handicapped or receive other services from the Michigan Commission for the Blind and give my permission for them to certify my eligibility.
Yes_______   No ________

If you answered “NO” to the above question, you must include with this application a letter from one of the following certifying that you are blind or unable to read a printed newspaper. 
______Your doctor
______Social Security award letter
______President of local chapter or state affiliate of the National  Federation of the Blind
______Educational institution
______Private agency for the blind

I am currently not known to the Michigan Commission for the Blind, but would like to have my name referred so that I can take advantage of their services.
Yes________   No ________

I certify that I am blind or visually impaired or unable to read a printed newspaper and request that the necessary certification is obtained either from my enclosed information or from the source indicated above. 

SIGNATURE______________________________ 

DATE______________

Please return this completed form to the above address. 
Please specify if you would prefer Braille (when available).__________

Office Use Only:
ID# ______ SEC# ____ Date number given _____.

This page was last modified October 16, 2006 11:28 PM EST.