THE METROPOLITAN WASHINGTON EAR, INC.

12061 Tech Rd, Silver Spring, MD 20904

(301) 681-6636 Fax--(301) 625-1986


APPLICATION for DIAL-IN and/or RADIO READING SERVICE





Today's Date:
Last Name: First Name: Middle Initial:


Street Address:
City:
State (two capital letters): ZIP+4:
County:
E-mail Address:
Home Telephone: Daytime Telephone:
Birth Date:
Occupation:
Highest academic credential:



Where did you learn about Metropolitan Washington Ear?



Living Arrangements:


Name of Home, if applicable:
Specify type of Legal Blindness or Physical Impairment:

All of our services are free, but voluntary contributions are greatly appreciated.  Please note that a subscription to a newspaper would be at least $15 monthly. The Metropolitan Washington Ear, Inc. is a private, non-profit 501 (c)(3) corporation, and is not a part of any organization, Library or Government Agency.

I have read the Agreement for Dial-In Service and Agree to its terms:
I have read the Agreement for Radio Reading Service and Agree to its terms:

Please list contact information for two persons in the event the applicant is not available.  
Last Name: First Name: Middle Initial:


Street Address:
City:
State (two capital letters): ZIP+4:
E-mail Address:
Telephone:
Last Name: First Name: Middle Initial:


Street Address:
City:
State (two capital letters): ZIP+4:
E-mail Address:
Telephone:

Choose the media type of instructions for using the services:

Before you submit an application please have the Certificate of Disability completed and faxed or mailed to

THE METROPOLITAN WASHINGTON EAR, INC.

12061 Tech Rd, Silver Spring, MD 20904

(301) 681-6636 Fax--(301) 625-1986


If you are a certified member of the Library of Congress Talking Books or the Martin Luther King Jr. Library Adaptive Services Division in DC, you will not need to have a Certificate of Disability filled out by an appropriate authority (i.e., ophthalmologist, medical doctor, optometrist, head of agency, occupational therapist, nurse, professional staff of health and welfare agencies, teacher of the handicapped, or other appropriate authority).