Name	Telephone	(	)

Telephone (evening)	(	)	Sex

Telephone (daytime)	(	)	Date of Birth

City	Parish	State	ZIP

Name (Last)	(First)	(Initial)

Application for Free Library Service: Individuals

National Library Service
for the Blind and
Physically Handicapped
Notice: Records relating to recipients of Library of Congress reading material are confidential except for those portions defined by local law as public information. To find out the extent to which the information provided on this application form may be released to other individuals, institutions, or agencies, consult the agency to which you are submitting this application.
This completed application should be sent to:

State Library of Louisiana 
Services for the Blind and Physically Handicapped
701 North Fourth St.
Baton Rouge, LA 70802-5232
Phone: 1-800-543-4702
Please Print or Type
Street address
Please give the name of a person to contact if you cannot be reached for an extended period:
 By law, preference in lending of books and equipment is given to veterans. Please check here if you have been honorably discharged from the armed forces of the United States.
Indicate the primary disability preventing you from reading standard printed material. See definitions under eligibility criteria, section A, page 4. Check only one box.
 Blindness
 Visual handicap
 Physical handicap	 Deaf-blind
 Reading disability (Requires M.D. signature)