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

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

SECTION 2: PARENTAL INFORMATION (REQUIRED IF APPLICANT IS UNDER 18)

Name of Parent(s) or Guardian(s) (required)

Parent/Guardian's Address (required if different from applicant) 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: DISABILITY TYPE AND CERTIFICATION (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 Individual Education Plan (IEP) or 504 plan for the applicant? Yes No Don't know or N/A

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 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 applicant. It is no way a comprehensive list. If you have any questions about who is a qualified certifying professional, please visit www.rfbd.org/certification.htm or call Member Services 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.

NOTE: Due to U.S. Copyright law, RFB&D does not offer distribution of RFB&D's downloadable AudioAccessSM or 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 Member Services at 609-452-0606 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
Daytime Telephone
E-mail

SECTION 4: INDIVIDUAL MEMBERSHIP AGREEMENT & COPYRIGHT ACKNOWLEDGMENT

Please read the statement below and sign at the bottom. Your membership application cannot be processed without a signature.

Membership Agreement
An individual membership is valid for one (1) year, unless otherwise noted as part of a promotional or trial offer. Your account will be permitted the customary 35 book limit.

Copyright Acknowledgement
The contents of all RFB&D books are protected under copyright law. 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 books in any form to any person is strictly prohibited by law and is a violation of publishers’ right and the terms of your membership. Violators face a permanent suspension of RFB&D membership benefits and possible civil or criminal penalties.

Acceptance
Under penalty of perjury (see 17 U.S.C. 506(a), 1201-1204 and 18 U.S.C. 1001, 2319, and related statutes), 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 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.

Cancellations and Refunds
Members may cancel their membership for a full refund within 30 days of your membership’s start date. Otherwise, you forfeit your membership fees. Any audiobooks still in your possession must be destroyed.

If you opt to cancel your membership and do not wish to keep any equipment you may have purchased, you must contact Member Services to request a Return Material Authorization (RMA) within 30 days of shipment of that equipment.

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)

Print Name:
Date:

SECTION 5: SELECTION OF INDIVIDUAL MEMBERSHIP TYPE

Schools that have identified RFB&D's audiobooks as an appropriate accommodation for students eligible for services under federal disability legislation, including the Individuals with Disabilities Education Act (IDEA) and section 504 of the Rehabilitation Act of 1973, are required to provide free access to those books

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, applicants elect 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 own school's 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 U.S. Department of Education, Office of Special Education and Rehabilitation Services at www.ed.gov. You may also call the U.S. Department of Education at 800-872-5327.

PLEASE SPECIFY TYPE OF MEMBERSHIP

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 10 must be completed)

NOTE: If your school has indicated that RFB&D's audiobooks are an appropriate accommodation, but declines to support the payment of membership fees, please call 800-221-4792.

Personal Individual Membership (Option 2)
I will pay for my membership personally (Please include payment in the amount of $100 - see section 10 for payment options).

Financial assistance is available to eligible members. Please contact Member Services 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 our product and services, and information on ways you can help RFB&D's mission.

SECTION 6: AUDIOBOOKS (YOUR MEMBERSHIP INCLUDES SEVERAL AUDIOBOOK FORMAT CHOICES)

AudioPlus books on CD and downloadable

All AudioPlus books are recorded in DAISY format to play on specialized DAISY playback systems.
No matter how you choose to receive your AudioPlus books, features remain the same: enhanced navigation so users can move easily from page to page or chapter to chapter, variable speed playback and bookmarking capabilities.
We offer DAISY equipment and software for sale. Visit www.rfbd.org for product information or call Member Services at 800-221-4792.
AudioPlus CDs are shipped Free Matter for the Blind & Other Physically Handicapped Persons which can take up to two weeks to arrive. See the UPS shipping rates in the Shipping section for other options.

AudioAccess enables downloading of audiobooks

Audiobooks ordered through AudioAccess can only be ordered using our online catalog. Once you receive your welcome letter you can activate your online account and begin ordering.
AudioAccess digital files sync easily between Microsoft Windows-based computers and compatible media players. For more information, visit http://support.rfbd.org or call product support at 800-772-3248.

I would like to order the following AudioPlus books on CD:

Book 1 Title
Author
Quantity
RFB&D Shelf #

Book 2 Title
Author
Quantity
RFB&D Shelf #

Book 3 Title
Author
Quantity
RFB&D Shelf #

SECTION 7: PLAYBACK EQUIPMENT (FOR AUDIOPLUS BOOKS ON CD ONLY)

Playing RFB&D's audiobooks requires special equipment. Visit www.rfbd.org and click on the "Players and Accessories" button to view our entire line of players. Note: Equipment is shipped UPS Ground

Playback Equipment 1 QTY Model Price

Playback Equipment 2 QTY Model Price

Playback Equipment 3 QTY Model Price

Equipment Total

SECTION 8: SHIPPING

SHIPPING RATES FOR UPS GROUND
number of items	rate
1-5 items	$10.00
6-15 items	$15.00
15 or more items	Please call for rates

Please provide a street address. UPS will not ship to a PO Box. For shipments to Alaska and Hawaii, please call Member Services at 800-221-4792.

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

SECTION 9: TOTALS

Membership Fee Total
Equipment Total
Shipping Total
Grand Total

SECTION 10: PAYMENT INFORMATION

Promotional Code (If applicable)

Method of Payment Check (Make check payable to: RFB&D, 20 Roszel Road, Princeton, NJ 08540)
Purchase Order (Make PO payable to: RFB&D, 20 Roszel Road, Princeton, NJ 08540)
Purchase Order # (Please attach PO)
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) Billing Address, Line 1
Billing Address, Line 2
City State
Zip Country

Thank you for completing this 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

© 2009, Recording for the Blind & Dyslexic, Incorporated. All Rights Reserved.
Recording for the Blind & Dyslexic®, RFB&D®, Learning Through Listening®, AudioAccessSM, the Heart and Headphones design, and all trademarks and service marks are owned by Recording for the Blind & Dyslexic, Incorporated.

3/09
CM-INDIVAPP

RFB&D® Use Only ID# Entry Date
SO# Initials