FORM 1 – PERSONAL APPLICATION

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

First Name:
Last Name:

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

I have a specific learning disability (please note that visual impairment alone does not indicate eligibility for this award)
I have been registered as an RFB&D member for at least one year, up to and including the period of March 1, 2006 — March 1, 2007, and have borrowed at least one RFB&D book during that time (individually or through a school)
I am a member of the 2007 graduating class of a public or private school or home school in the United States or its territories, including US military installations
I have an overall grade average of B or above (or equivalent), based on grade levels 10 through 12
I plan to continue my formal education beyond high school at either a two- or four-year college or vocational school

Home Address (line 1):
Home Address (line 2):
City: State: Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip: Telephone:
E-mail: Date of Birth:
Anticipated Graduation Date: Grade Point Average:
Describe your particular disability:

Are you registered with RFB&D individually or through a school?
individually through a school
If individually, provide membership #:
If through a school or school district, provide name and telephone number:
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 high school currently attending:

School Address (line 1):
School Address (line 2):
City: State: Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip: Telephone:
Name of school you will be attending next year (two- or four-year college or vocational study):
If you have not selected a college, please list the schools to which you have applied:

SIGNATURE

Your signature constitutes a pledge that this application is accurate to the best of your 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 (and guardian, if under age 18) 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: ____________________
Signature of parent or guardian:
________________________________________________________________________
Date: ____________________
(required if applicant is under 18 years of age)
Name of parent or guardian:

RFB&D USE ONLY: Inst. Ind.   Reg. Date: ________ Exp. Date: ________