Click if address is a Nursing Home Residential Care Facility

Name of Facility

Marital Status Select One Married Divorced Widowed Single Spouse's Name

Birth Date Years of Education Read Braille? Select One Yes No Hard of Hearing? Select One Yes No

Check here if employed Place of Employment

Ethnicity Select One African-American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Hispanic White Other Annual Household Income Select One Less than $10,000 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $29,000 $30,000 - $39,999 $40,000 - $49,999 $50,000 or more

How did you first hear about Minds Eye Information Service?

2 Family members with different addresses and phone numbers:

Name Relationship

Address Phone Number

Name Relationship

Address Phone Number

APPLICANT'S AUTHORIZATION AND AGREEMENT:

I have signed on the space below, or have personally requested this service and have authorized that this application be signed on my behalf.
I authorize the release by an agency, physician, or clinic of pertinent medical data to determine my eligibility for Minds Eye Information Service.

I understand that if I qualify for service, I will be loaned a radio which is the property of Minds Eye Information Service and must be
returned when I no longer need the service.

Applicant's Signature Date

(OR)

Signature of Person signing for Applicant Date

The specific medical diagnosis of applicant's visual/physical handicap is:

Certified by: Date:

Title: (Physician, Counselor, Social Worker, etc)

Address

Phone Number