Recording for the Blind and Dyslexic - Application for Learning Through Listening Institutional Membership

RECORDING FOR THE BLIND & DYSLEXIC®

Application for
Learning Through Listening® (LTL®)

INSTITUTIONAL 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 listed below.
Note: Specialized equipment required. Equipment is not included in price of membership. See Section 4b for information.
Please select your membership level:

Membership Level	Number of Audiobooks Annually	Typical Number of Students Served	Annual Fee
Level 1 Membership (Annual Fee: $350)	25	1-12	$350
Level 2 Membership (Annual Fee: $500)	50	13-25	$500
Level 3 Membership (Annual Fee: $950)	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

I agree to register all individuals using RFB&D’s recorded books as part of this program using the Student Certification Form that will be provided by RFB&D® in my Welcome Packet.
I agree to submit the completed Student Certification Form to RFB&D by the end of my membership year. I understand that RFB&D cannot process a membership renewal without a completed Student Certification Form.
I agree that all individuals I register with RFB&D have a learning disability, visual impairment or other physical disability that limits their ability to effectively read standard print. This disability will be certified by a qualified professional. 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 that 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.

I agree to provide RFB&D’s books only to individuals registered with RFB&D through this Institutional Membership.
Our Learning Through Listening (LTL) Institutional Membership is valid for one year. Should I choose not to renew my membership, I agree to return all RFB&D books borrowed.
I agree that our LTL Institutional Membership will provide services to only one school site.
I agree to the terms of the Cancellation Policy: Institutional LTL Members may cancel their membership for a full refund within 60 days of registration/renewal, as long as all books borrowed are returned. Cancellations made after 60 days will forfeit membership fees.

Copyright Acknowledgment

The contents of all RFB&D books are protected under copyright law. RFB&D strictly regulates its distribution of materials to a specialized 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 of the terms of your RFB&D Learning Through Listening Institutional Membership. Violations will subject your institution to permanent suspension of its RFB&D membership benefits and possible civil or criminal penalties.

As a representative of the educational institution named below, I understand the statements above and agree to all the terms and conditions of RFB&D’s Membership Agreement and Copyright Acknowledgement. I understand that copying, sharing or redistributing RFB&D’s books in any form, to any person may result in permanent suspension of RFB&D’s membership benefits, and possible civil and criminal penalties.

This agreement is binding for the entire membership year, regardless of the tenure of the agent of the institution whose signature appears below.

Signature of Authorized Agent (required)
Date (required)
Name
Title
Phone # Fax #
E-mail

SECTION 4a: 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 4b: SELECT PLAYBACK EQUIPMENT Playing RFB&D’s audiobooks requires special equipment. Set up your audiobook listening center immediately by ordering your playback equipment now. 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

Playback Equipment 3 QTY Model Price

Note: Equipment is shipped UPS

Equipment Total

SECTION 5a: SHIPPING

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 selected other than Free Matter):
Shipping Total:

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

SECTION 5b: TOTALS Membership Fee Total
Equipment Total
Shipping Total
Grand Total

SECTION 5c: 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 P.O.)
Credit Card

Credit Card Information Credit Card Type
Credit Card Number
Expiration: Month Year
Credit Card Authorization Signature

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.
®, TM “Recording for the Blind & Dyslexic,” “RFB&D,” “Learning Through Listening,” the Heart and Headphones Design, and all trademarks and trade names are proprietary to Recording for the Blind & Dyslexic, Incorporated.

Rev. 3/07 SC-INSTAPP