Illinois Talking Book and Braille Application for Free Service

APPLICATION FOR FREE LIBRARY SERVICE
Talking Book & Braille Service • Illinois State Library
401 E.Washington St., Springfield, IL 62701
800-665-5576, choose option 5

Please fill out the following application online. After typing in the requested information, print the form and take it to an appropriate certifying agent for final signature. Once the application has been certified, mail it to

ISLTBBS, 401 E. Washington, Springfield, IL 62701

Please Type or Print
Applicant's Name
Street Address
City	State Illinois	Zip
County	Home Phone:	Work Phone:
E-mail Address
Date of Birth mm/dd/yyyy	Sex Male Female
Name Of Person To Contact If You Cannot Be Reached For An Extended Period
Home Phone Number Of Person To Contact If You Cannot Be Reached For An Extended Period
By law, preference in lending books and equipment is given to veterans. Please check if you have been honorably discharged from the U.S. Armed Forces

Eligibility and Certification

Please check the primary disability preventing you from
reading standard printed material:

Blindness
Visual acuity is 20/200 or less in the better eye with correcting lenses, or the widest diameter of visual field subtends angular distance no greater than 20 degrees.

Visual Impairment
Visual limitation, with correction and regardless of optical measurement, prevents the reading of standard print material.

Physical Disability
Inability to read or hold standard print material as a result of physical limitations.

Reading Disability
Reading (learning) disability resulting from organic dysfunction and of sufficient severity to prevent reading printed material in a normal manner. (Note: In the case of reading disability, the application must be signed by a doctor of medicine or osteopathy.)

Deaf-Blind

In addition to any of the qualifying disabilities previously indicated, do you also have a hearing impairment? If yes, indicate degree of hearing loss:

Moderate
Inability to read or hold standard print material as a result of physical limitations.Some difficulty hearing and understanding speech.

Profound
Cannot hear or understand speech.

Books, Magazines, Equipment

Check those you wish to receive: Talking Books on cassette and cassette player (playback only) Braille Books Magazines A catalog of available magazines will be sent.

Choose one of the following players: Standard Cassette Player (recommended for most users) Plays 15/16 ips (inches per second), 4-track, Library of Congress cassettes. Also plays 1-7/8 ips, 2-track audio cassettes. Equipped with rechargeable battery and electrical cord. Easy Cassette Player Plays 15/16 ips, 4-track audio cassettes only. For persons with physical limitations that make use of the standard cassette machine difficult. Has limited controls, no battery, and must be plugged into an electrical outlet.

Machine Accessories

Machine Accessories: Headphones Issued solely for use where speakers are not permitted, as in nursing homes, schools or hospitals. Most commercially produced headphones are compatible with the cassette players. Amplifier Solely for use by readers with significant hearing loss. (Request a separate application.) Remote Control Unit For persons with limited use of their hands. Turns equipment on and off but will not control other functions such as volume and speed. (Request a separate application.) Breath Switch For persons with little or no use of their extremities. Must be used with remote control unit. Extension Levers For persons who have difficulty manipulating the key controls on the standard cassette machine. Attaches to the key controls of the cassette machine. Pillow Speaker For persons confined to bed.

Return of Equipment
Playback equipment and accessories are provided to eligible persons on extended loan. If this equipment is not being used in conjunction with recorded reading material provided by the Library of Congress and its cooperating libraries, it must be returned to the issuing agency. Materials may be returned through the U.S. Postal Service free of charge.

Type of service you wish to receive

Type of service you wish to receive: I want to select my own books. I will send requests from the catalogs provided by the Talking Book Center or other sources. I would like the Talking Book Center to select books for me according to my reading interests. Combination of above. This option ensures that I will still receive books even if my specific selections are unavailable.

if you are a student, what school do you attend?

Please check all that apply:

I need service at home

I need service at school

Certifying Authority
This section of the form can't be completed online. Please print the form below and take to a Certifying Authority.

To be completed by certifying authority (see definition of "certifying authority" below)
Please Type or Print
Certifying Authority Name
Title and Occupation
Street Address
Phone
City, State
Signature (Signature must be original; faxes or photocopies are not accepted.)
Definition of "Certifying Authority"
1.	In cases of blindness, visual impairment or physical limitations, a "certifying authority" includes doctors of medicine; doctors of osteopathy; ophthalmologists; optometrists; registered nurses; therapists; and professional staff of hospitals, institutions, and public or private welfare agencies (e.g. social workers, caseworkers, counselors, rehabilitation teachers and superintendents). In the absence of any of these, certification may be made by professional librarians or by any person whose competence under specific circumstances is acceptable to the Library of Congress.
2.	In the case of reading disability from organic dysfunction, a "certifying authority" includes doctors of medicine and doctors of osteopathy who may consult with colleagues of associated disciplines.

Confidentiality
Records relating to recipients of Library of Congress reading material are confidential except for those portions defined by local law as public information. Laws governing confidentiality of library records can be found in the Illinois Compiled Statutes at 75 ILCS 70/1: "The registration and circulation records of a library are confidential information. Except pursuant to a court order, no person shall publish or make any information contained in such records available to the public."

You have now completed filling out the application. Once the application has been certified, mail it to

ISLTBBS, 401 E. Washington, Springfield, IL 62701