Nevada Public Radio - Radio Reading Service
Listener Application

First Name:

Last Name:

Address:

Apt./Unit#:

City:

State:

Zipcode:

E-mail:

Telephone:

Year of Birth:

Male   Female

Reason requesting service

Legally Blind - Visual acuity of 20/200 or less in the better eye with correcting glasses, or the widest diameter of visual field subtending an angular distance no greater than 20 degrees.

Partial Vision - Inability to read standard printed material without special aids or devices other than regular glasses.

Physical Handicap - Inability to read or use standard printed material as a result of physical limitations, paralysis, missing arms or hands, extreme weakness.

Reading Disability - Organic dysfunction of sufficient severity as to prevent reading print.

Other Disability - Please specify.

Any of the above conditions must be certified by competent authorities. These include medical doctors, ophthalmologists, optometrists or social workers and rehabilitation counselors.

Are you using the Talking Book Program?

Yes   No

Are you registered with Bureau Services to the Blind?

Yes   No

By submitting this application you give permission to either of the above to release certifying information.

If you do not use the Talking Book Program or are not registered with Bureau Services to the Blind, please provide an alternative certifying authority.

Name:

Title:

Telephone:

(If you have other certification documentation you may send a copy to the address below.)

An annual $30 donation is requested for receiver use.

The receiver which we will be sending remains the property of the Radio Reading Service and is loaned to you for as long as you wish. Please notify our office if you move. We will need your new address and telephone number for future correspondence.

Please provide the name, address and telephone number of a family member or friend who will be our backup contact.

Name:

Address:

City:

State:

Zipcode:

Telephone:

Relationship: