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:
Mr.
Mrs.
Ms.
Dr.
Street Address:
City:
State (two capital letters):
ZIP+4:
County:
E-mail Address:
Home Telephone:
Daytime Telephone:
Birth Date:
Occupation:
Highest academic credential:
High School Diploma
Bachelor's Degree
Master's Degree
Doctorate
None of the Above
Where did you learn about Metropolitan Washington Ear?
Library
Internet
Eye Doctor
Telephone Directory
None of the Above
Living Arrangements:
Live alone
Member of household
At school
At nursing home or retirement home
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:
Mr.
Mrs.
Ms.
Dr.
Street Address:
City:
State (two capital letters):
ZIP+4:
E-mail Address:
Telephone:
Last Name:
First Name:
Middle Initial:
Mr.
Mrs.
Ms.
Dr.
Street Address:
City:
State (two capital letters):
ZIP+4:
E-mail Address:
Telephone:
Choose the media type of instructions for using the services:
Tape
Large Print
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).