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

SECTION 1: SCHOOL/INSTITUTION INFORMATION

School/Institution Name (required)
Tax ID#

School/Institution Address (required) School/Institution Address, Line 1
School/Institution Address, Line 2
City State
Zip

Primary Contact Information Primary Contact (required)
Primary Contact Phone (required)
Fax
E-mail Address (required)

Delivery Information

Delivery Address (required if different from school/institution address. NO PO BOXES, PLEASE) Delivery Address, Line 1
Delivery Address, Line 2
City State
Zip

Delivery Contact (if different from Primary Contact)
Delivery Phone
Delivery Fax

Billing Information

Billing Address (required if different from school/institution address) Billing Address, Line 1
Billing Address, Line 2
City State
Zip

Billing Phone
Billing Fax

Membership Options (required)

Select your Membership Level	Number of Audiobooks Annually	Typical Number of Students Served	Annual Fee
Level 1	25	1-12	$350
Level 2	50	13-25	$500
Level 3	100	26-40	$950

SECTION 2: DISABILITY DECLARATION

Please indicate the educational level of the students you will serve through this membership: Elementary
Middle
High School
College/University
Graduate School
Adult

Please indicate the disability that limits your students’ ability to read standard print effectively (check all that apply): Blindness/Visual Impairment
Learning Disability
Other Physical Disability

Do any of the students you serve use braille? Yes No

SECTION 3: MEMBERSHIP AGREEMENT & COPYRIGHT ACKNOWLEDGEMENT

Membership Agreement

Through this LTL Membership, I agree to provide RFB&D® books only to students who meet the print-disability requirements: all students who use RFB&D's books have a learning disability, visual impairment or other physical disability which limits their ability to effectively read standard print. This disability will be certified by a competent authority.
Appropriate certifying experts may differ from disability to disability. If you have any questions about who is a competent authority, please visit www.rfbd.org/certification.htm or call Member Services at 800-221-4792.
I agree to certify all students using this program by submitting the Student Certification form provided by RFB&D by the end of my membership year. I understand that RFB&D cannot process a membership renewal without this completed form.
Our LTL membership is valid for one year. Should I choose not to renew I will destroy all RFB&D books in my possession.
I agree to provide services to only one school site.
LTL members may cancel their membership for a full refund within 60 days of registration or renewal.
The Individuals with Disabilities Education Act (IDEA) requires RFB&D to ensure that no portion of the costs associated with institutional membership are incurred by students. In accordance with that requirement, I agree not to pass along any costs associated with RFB&D membership to the students being served through this membership.

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’ rights 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 statues), 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.

Signature of Authorized Agent (required)

Date (required)
Name
Title
Phone # Fax #
E-mail

SECTION 4: 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 5: 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 6: SHIPPING

SHIPPING RATES FOR UPS GROUND
number of items	rate
1-5 items	$15.00
6-10 items	$25.00
11-15 items	$40.00
16 or more items	Please call for rates

Please provide 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 7: ORDER TOTAL

Membership Fee Total
Equipment Total
Shipping Total
Grand Total

SECTION 8: 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 shipping) 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®, the "Heart and Headphones" design and all trademarks are owned by Recording for the Blind & Dyslexic, Incorporated.

3/09
CM-INSTAPP