RFB&D Application for Individual Membership

RECORDING FOR THE BLIND & DYSLEXIC®

Application for Individual Membership
Learning Through Listening® (LTL®)

Complete all sections and be sure to include correct payment. Incomplete applications will be returned.

SECTION 1: APPLICANT INFORMATION

Applicant's Name (required) First Last

Date of Birth (required) Month Day Year

Citizenship/Residency Information: Is the applicant a U.S. citizen? (required) Yes No
If no, is the applicant residing in the U.S.? (required) Yes No
If no, list country

Veteran Status: Is the applicant a veteran? Yes No

Home Address/Phone (required) Home Address, Line 1
Home Address, Line 2
City State
Zip Country
Home Phone

Mailing Address (required if different from home address) Mailing Address, Line 1

Mailing Address, Line 2
City State
Zip Country

Contact Information: Daytime Phone
Fax
E-mail Address (Required if you plan to order audiobooks and players online and to receive regular membership updates and book and product news)

Student Information: Is applicant a student? (required) Yes No
If yes, what is the current grade?

Please check the type of educational setting Public School
Private School
Undergraduate/Graduate College
Other

School Information: Name of School/Institution
School Address, Line 1
School Address, Line 2
City (required) State (required)
Zip (required) Country (required)
School Contact Name
Phone E-mail

How did you hear of RFB&D?

The following question is for statistical purposes only and is optional.
Household Annual Income Level $0-$25,999
$26,000-$50,000
$51,000-$75,000
$76,000-$99,000
$100,000+

SECTION 2: PARENTAL INFORMATION (REQUIRED IF APPLICANT IS UNDER 18)
Name of Parent(s) or Guardian(s) (required)

Parent/Guardian's Address, if different from applicant (required) Parent/Guardian's Address, Line 1

Parent/Guardian's Address, Line 2
City State
Zip Country

Parent or Guardian's Phone (required)
Parent or Guardian's E-mail

SECTION 3: COPYRIGHT ACKNOWLEDGMENT (REQUIRED)
Please read the statement below and sign at the bottom. Your membership application cannot be processed without a signature.

The contents of all RFB&D books are protected under copyright law, and thus require special playback equipment. RFB&D strictly regulates the distribution of materials within a qualified member population that has provided documented evidence of a print disability. Copying, sharing or redistributing RFB&D's books in any form to any person is strictly prohibited by law and is a violation of publishers' right and the terms of your RFB&D membership. Violators face a permanent suspension of RFB&D membership benefits and possible civil or criminal penalties.

I understand the statement above and agree to all terms and conditions of RFB&D membership. I agree not to copy, share or redistribute RFB&D's books in any form, to any person. I understand that to do so may result in permanent suspension of RFB&D membership benefits and possible civil or criminal penalties.

By signing, I agree to the terms of the copyright acknowledgment and agree to receive services, or, if I am a parent or guardian signing on behalf of a minor, agree for my child to receive services from RFB&D.

Applicant's Signature (or Parent/Guardian if applicant is under 18 years old) (required)

Print Name:
Date:

Cancellations
Members may cancel their membership for a full refund within 90 days of registration, as long as any books borrowed are returned. Cancellations made after 90 days will forfeit membership and registration fees.

SECTION 4: DISABILITY DECLARATION (REQUIRED)

Please indicate the disability that limits the applicant's ability to read standard print effectively (Check all that apply) Visual Impairment
Learning Disability
Other Physical Disability

Does applicant read braille? Yes No

Does the school have an Individualized Education Plan (IEP) for the applicant? Yes No Don't know or N/A

SECTION 5: DISABILITY CERTIFICATION (REQUIRED)
Option 1
Please have the following certification completed by a qualified professional in the field of disability services, special education, medicine or psychology. The certifier must be a recognized expert who attests to the physical basis of the visual, perceptual or other physical disability that limits the applicant's use of standard print.

Appropriate certifying experts may differ from disability to disability. The following lists examples of professionals who are qualified to certify an RFB&D applicant. It is in no way a comprehensive list. If you have any questions about who is a qualified certifying professional, please call RFB&D's Member Services department at 800-221-4792.

In the case of blindness and visual impairments an appropriate certifier may be a physician, ophthalmologist, or optometrist.
In the case of a perceptual disability, a neurologist, learning disability specialist or psychologist with a background in learning disabilities may be the most qualified certifying professional.
The following professionals or individuals are NOT typically qualified to attest to the basis of a disability which limits the applicant's ability to effectively read standard print, unless they have a background in one of the above areas of expertise: principals, vice-principals, guidance counselors, general education teachers, librarians.

Option 2
If you are receiving services from The National Library Service for the Blind and Physically Handicapped (NLS) or its cooperating network libraries, we will accept a signature from one of their librarians in place of Option 1. For applicants in Canada or the United Kingdom: If you are registered with the Canadian National Institute for the Blind (CNIB) or the Royal National Institute for the Blind (RNIB), you may send proof of this registration in place of the information requested above. Note that RFB&D does not offer distribution of RFB&D's AudioPlus® books on CD outside of the United States, except to U.S. citizens who are temporarily residing abroad. However, RFB&D has other options available to our international members. Please call the Member Services department at 800-221-4792 for details.

Certification Statement
The following information is required in order to process applicant's membership:

I attest to the physical basis of the visual, perceptual or other disability limiting the applicant's ability to effectively use standard print. I also attest to my competency to make this certification.

Name of Certifying Professional (Please print):

Signature
Title/Professional Specialty
Place of Employment
Address, Line 1
Address, Line 2
City State
Zip Country
Daytime Telephone
E-mail

SECTION 6: SELECTION OF INDIVIDUAL MEMBERSHIP TYPE (REQUIRED)
Schools that have identified RFB&D's recorded books as an appropriate accommodation for students are required to provide access to RFB&D's recorded books in compliance with federal disability legislation including the Individuals with Disabilities Education ACT (IDEA) and Section 504 of the Rehabilitation Act of 1973.

Option 1
If you are in school and have a documented print disability, choose the Student Individual Membership option and submit this completed form to the school for payment. Please note that schools may be registered as an RFB&D Learning Through Listening Institutional Member, through which the applicant's need may be met. A school may decline payment for a Student Individual Membership if it believes its own LTL Institutional Membership offers the applicant an appropriate accommodation.

Option 2
Alternatively, by selecting the Personal Individual Membership option, the applicant elects to pay membership fees directly to RFB&D. Applicants may choose this type of membership for a variety of reasons. For example, they may wish to borrow books that are not part of their schools' curricula, they may not be enrolled as students, or they may have other personal needs.

For more information on the rights of students with disabilities, visit the US Department of Education, Office of Special Education and Rehabilitation Services at www.ed.gov/offices/OSERS. You may also call the U.S. Department of Education at 800-872-5327.

PLEASE SPECIFY TYPE OF MEMBERSHIP for (applicant's name)

Students Individual Membership (Option 1)
My school will pay for my membership (A Check or Purchase Order from the school in the amount of $100 must be attached, or credit card information in section 8c must be completed)

Personal Individual Membership (Option 2)
I will pay for my membership personally (Please include payment in the amount of $100 - see section 8c for payment options)

Financial assistance is available to eligible members. Please contact RFB&D's Member Services Department at 800-221-4792 for more information.

NOTE: All information on this application is considered confidential. RFB&D does not sell to, trade to, or otherwise share member information to any third parties; however, in conjunction with RFB&D's funding programs, aggregate data may be provided to agencies and institutions when needed for verification purposes or to illustrate the extent of services rendered. You may also receive communications regarding RFB&D's product and services, and information on ways you can help RFB&D's mission.

SECTION 7a: AUDIOBOOKS

Please include your first book order to activate your account. If you don't select a book, RFB&D will choose one for you. Visit www.rfbd.org to search online or call RFB&D's Member Services at 800-221-4792 for book ordering assistance. Our audiobooks are shipped FREE MATTER which takes approximately two weeks to arrive. If you would like to pay for UPS Ground shipping, please check the UPS box below.

Choose shipping method: Free Matter UPS

I would like to order the following books:

Book 1 Title
Author
Quantity
RFB&D Shelf #

Book 2 Title
Author
Quantity
RFB&D Shelf #

Book 3 Title
Author
Quantity
RFB&D Shelf #

Book 4 Title
Author
Quantity
RFB&D Shelf #

Book 5 Title
Author
Quantity
RFB&D Shelf #

Book 6 Title
Author
Quantity
RFB&D Shelf #

Book 7 Title
Author
Quantity
RFB&D Shelf #

Book 8 Title
Author
Quantity
RFB&D Shelf #

Book 9 Title
Author
Quantity
RFB&D Shelf #

Book 10 Title
Author
Quantity
RFB&D Shelf #

SECTION 7b: SELECT PLAYBACK EQUIPMENT

In order to play RFB&D digitally recorded textbooks, you will need to use specially adapted CD players or software. RFB&D offers a complete line of players, software and accessories. Visit www.rfbd.org and click on the "Players and Accessories" button to view our entire line of players.

Playback Equipment 1 QTY Model Price

Playback Equipment 2 QTY Model Price

Note: Equipment is shipped UPS; no PO Boxes please.

Equipment Total

SECTION 8a: SHIPPING

For shipments to Alaska and Hawaii, please call Member Services at 800-221-4792.

SHIPPING RATES FOR UPS GROUND
number of items	rate
1-5 items	$6.50
6-15 items	$11.50
15 or more items	Please call for rates

SECTION TOTAL
# of books
UPS cost (If other than Free Matter)
Shipping Total

UPS will not ship to a PO Box; please ensure you have provided a street address.

Note: For 16 or more items, or for other shipping services, including overnight, call 800-221-4792.

SECTION 8b: TOTALS
Membership Fee Total
Equipment Total
Shipping Total
Grand Total

SECTION 8c: PAYMENT INFORMATION

Method of Payment Check or Purchase Order (Make check/PO payable to: RFB&D, 20 Roszel Road, Princeton, NJ 08540)
Purchase Order # (Please attach PO)
Promotional Code (If applicable)
Credit Card

Credit Card Information Credit Card Type
Credit Card Number
Expiration: Month Year
Credit Card Authorization Signature
Name on Credit Card (please print)
Billing Address (if different from applicant's), Line 1
Billing Address, Line 2
City State
Zip Country

Membership, equipment and shipping prices are all subject to change without notice.

Thank you for completing RFB&D's Membership Application. We look forward to serving you!

20 Roszel Road, Princeton, New Jersey 08540 • 800-221-4792 • www.rfbd.org • Fax: 609-987-8116

© 2007, Recording for the Blind & Dyslexic, Incorporated. All Rights Reserved.
Recording for the Blind & Dyslexic®, RFB&D®, Learning Through Listening®, the "Heart and Headphones" design and all trademarks are owned by Recording for the Blind & Dyslexic, Incorporated.

7/07
CM-INDIVAPP

Office Use Only ID# Entry Date
SO# Initials