Please print or type:
(street name or route)
(apartment or box number)
City State Zip + 4
County Phone: home ( )
work ( )
Date of Birth
By law, preference in lending of books and equipment is given to veterans. Please
check here if you have been honorably discharged from the Armed Forces of the
Eligibility and Certification
Please check the primary disability preventing you from reading standard print:
Visual acuity of 20/200 or less in the better eye with correcting lens,
or the widest diameter of visual field is no greater than 20 degrees.
Inability to read standard printed materials without special aids or
Impairment devices other than regular glasses.
Inability to read or use standard printed materials as a result of physical
limitations, e.g., paralysis, lack of arms or hands, extreme weakness.
Disability must be physically based (an organic dysfunction) and of
sufficient severity to prevent reading regular or standard printed
materials in a normal manner. Application must be signed by a
doctor of medicine or osteopathy.
Application for Free Library Service:
Robin Carnahan, Secretary of State
PO Box 387, Jefferson City, MO 65102-0387
Telephone: (800) 392-2614
In addition to any of the previously indicated conditions, do you also have a hearing
loss? If yes, please indicate the degree:
Moderate (some hearing loss)
Profound (major hearing loss)
Qualified readers must be residents of the United States, including the 50 states, terri-
tories, insular possessions, and the District of Columbia, or American citizens tem-
porarily living abroad.
Definition of “Certifying Authority”
1. In cases of blindness, visual impairment, or physical disability, certifying
authorities include doctors of medici