Individual Application

Note: A user can enter information directly into this form using the computer then print the completed form or can print the form and complete it with pen. All applications should be sent to the Nebraska Talking Book and Braille Service. You can fax your application to 1-402-471-6244, email a scanned copy of your application to, or mail your application to Talking Book and Braille Service, The Atrium, 1200 N St, Ste 120, Lincoln, NE 68508-2023. Note Also: Records relating to recipients of Library of Congress reading material are confidential.

Navigation: Applicant Information | Alternate Contact Person
Certification of Eligibility | Services | Borrower Agreement
Reading Interests | Survey

Applicant Information:
Applicant Contact Information:

Other Applicant Information: Hearing Loss:

Alternate Contact Person:
Alternate Contact Information:

Certification of Eligibility: (Eligibility Information)

Eligibility must be certified by one of the following: doctor of medicine, doctor of osteopathy, ophthalmologist, optometrist, psychologist, registered nurse, therapist, or professional staff of hospitals, institutions, and public or welfare agencies (such as an educator, social worker, case worker, counselor, rehabilitation teacher, certified reading specialist, school psychologist, superintendent, or librarian).

Select Applicant Eligibility Reason:
Authority Contact Information:

Certify Applicant Eligibility: I certify that the applicant named is unable to read or use standard printed material for the reason indicated above.

Services Preferred: (Collection Information) Books/Magazines (Postage-Free USPS Delivery/Pick-Up)
Books/Magazines (Postage-Free USPS Delivery/Pick-Up)
Books/Magazines (Audio and Braille Materials Available)
Equipment Information: (Please check the box to show you have read the statement below.)

Borrower Agreement:
(Please follow the links within the text below and review the material covered before agreeing.)

Reading Interests:
Request Type:
Foreign Languages: (Only need specify if English is not your first language)
Content Exclusions: (Select whatever contents you wish the books not contain (check all that apply))
Reading Levels:

Note: Please choose up to ten subjects from the nonfiction and fiction subjects listed below.

Nonfiction Subjects: (Prose writing that is based on facts, real events, and real people, such as biography or history.)

Fiction Subjects: (Literature in the form of prose, esp. short stories and novels, that describes imaginary events and people.)

How did you hear about this service? (Check up to three.)