FORM 1 - PERSONAL APPLICATION

Please type or clearly print and include ONLY the information that is requested in the spaces below.

To apply for this award, you must be able to respond affirmatively and check all of the following eligibility criteria:

I am legally blind
I have been registered as an RFB&D member for at least one year, up to and including the period of March 2, 2008 — March 2, 2009 (individually or through a school)
I have received, or will receive, a bachelor’s, master’s or doctoral degree from an accredited four-year college or university in the United States or its territories between July 1, 2008, and June 30, 2009
I have an overall grade point average for my undergraduate years of 3.0 or more on a 4.0 scale (or equivalent if an alternative grading system is used)

First Name:

Last Name:

Home Address, line 1:

Home Address, line 2:

City:

State: Zip:

Telephone:

E-mail:

Date of Birth: Date of Graduation:

Undergraduate or graduate degree granted between July 1, 2008, and June 30, 2009:

BA BS Other other

Major:

Minor:

3½- or 4-year grade average (rated on a 4.0 scale):

Describe your particular visual disability:

Totally Blind Legally Blind

Are you registered with RFB&D individually? Yes No

If Yes, provide ID #

If you have a membership through an institution/school, provide details below:

Name/Membership # of institution/school:

Address, line 1:

Address, line 2:

City:

State: Zip:

Contact Name:

Telephone:

Duration of your membership?

Approximate number of RFB&D audiobooks read in the last 3 years (or, if membership is under 3 years, during your membership):

Name of school currently attending:

City (if different from above):

State: Zip:

Telephone:

SIGNATURE

The applicant’s signature constitutes a pledge that this application is accurate to the best of their knowledge, that the application is entirely the work of the applicant and that the applicant meets all of the eligibility criteria. In addition, by signing this form, the applicant agrees to participate in RFB&D media activities and gives RFB&D the absolute right and permission to feature the name, photograph, videotape, quotes and/or information about the applicant in any RFB&D publication and/or public relations materials; and hereby waives the right to approve the finished product(s).

Signature:

Date:

RFB&D USE ONLY:

Inst. Ind. Reg. Date: Exp. Date: