THE METROPOLITAN WASHINGTON EAR, INC.

35 University Boulevard East, Silver Spring, MD 20901

(301) 681-6636 Fax--(301) 681-5227

APPLICATION for DIAL-IN and/or RADIO READING SERVICE

If you are not a certified member of the Library of Congress Talking Books or a member of The Ear, you will need to have a Certificate of Disability filled out by an appropriate authority (i.e., opthamologist, medical doctor, optometrist, head of agency, occupational therapist, nurse, professional staff of health and welfare agencies, teacher of the handicapped, or other appropriate authority) Before you submit an application. Please have the Certificate of Disability completed and faxed or mailed to the

Metropolitan Washington Ear
35 University Boulevard East
Silver Spring, MD 20901

Fax--(301) 681-5227

APPLICATION

Enter the Date:

I am applying for:
Dial-in Service. Please read the Dial-in Service Agreement which specifies the terms and conditions for receiving the service.
Radio Reading Service. Please read the Radio Reading Service Agreement which specifies the terms and conditions for receiving the loaner radio.

All information you submit will be held confidential

Last Name: First Name: Middle:
Mr. Mrs. Ms.

Street Address
City
State
Zipcode
*Please add the last 4 digits of your zipcode

County

E-mail address

Telephone: (H)
Daytime: (O)
Birth date:
Occupation
Social Security No.

Education:
High School
College
Grad.School
Other

How did you hear about us?
Library
Internet
Ophthalmologist
Telephone Directory
Other

Where do you live?
Alone
Member of Household
At School
Nursing or Retirement Home

Name of Home? If applicable

Please specify type of Legal Blindness or Physical Impairment:

I have read the Dial-in Service Agreement and agree to its terms:

I would like Dial-In News instructions in:
Large Print
Tape

I have read the Radio Reading Service Agreement and agree to its terms:

You can go back and correct any entry
or you can:
Erase the form and start over:
The information is correct. Submit the form:

We hope that you will regularly contribute to MWE, please note that a subscription to a newspaper would be at least $10 monthly. The Metropolitan Washington Ear, Inc. is a private, non-profit corporation, and is not a part of any organization, Library or Government Agency .

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