FORM 1 – PERSONAL APPLICATION

Please type or clearly print 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 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 3, 2007— March 3, 2008 (individually or through a school)
I have received, or will receive, a bachelor’s degree from an accredited four-year college or university in the United States or its territories between July 1, 2007, and June 30, 2008
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)

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: Date of Graduation:
Undergraduate degree granted between July 1, 2007, and June 30, 2008:
BA: BS:  Other: Other Degree:
Major: Minor:
College Granting Degree:
3˝- 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 or through a college/university?
individually through a college/university
If individually, provide membership #:
If registered through a college/university or 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 school currently attending:

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:  
School’s E-mail:
Your Campus Address (line 1):
Your Campus 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:

SIGNATURE

Your signature constitutes a pledge that this application is accurate to the best of your knowledge, that the application is entirely your own work and that you meet all of the eligibility criteria. In addition, by signing this form, you agree to participate in RFB&D media activities and give RFB&D the absolute right and permission to feature your name, photograph, videotape, quotes and/or information in any RFB&D publication and/or public relations materials; and hereby waive the right to approve the finished product(s).

Signature: ________________________________________  Date: _______________

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