Institutional 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 nlc.talkingbook@nebraska.gov, 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 | Outreach

Institution Information:
Institutional Information:



Proposed Users:


Contact Person:
Contact Information:



Certification of Eligibility: (Eligibility Information)

Note: Have the form signed by a certifying authority, such as a medical professional, other professional staff of hospitals and nursing homes, social worker, caseworker, rehabilitation teacher and superintendent, or professional librarian. Those who need talking books because of a reading disability must submit an application that is signed by a medical doctor or doctor of osteopathy. Note Also: Family members may NOT serve as the ceritfying authority.

Authority Contact Information:



Certify Applicant Eligibility: I certify that the proposed users of the institution named are unable to read or use standard printed material because of blindness, visual impairment, or physical limitations. I further certify that the reading materials and equipment borrowed will be used by such persons only. (Signature of Certifying Authority)
____________________________________________________


Services:
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.)
Audio Player Accessories: (Special Conditions Apply)


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.)









Outreach:
(Optional)