WEYE Seeing Eye Radio of Goodwill Industries of Akron570 E Waterloo Road Akron Ohio 44319Local 3307246995 Tollfree 8009898428 Fax 3307862513 wwwgoodwillakronorg Contact Dave Binkley Manager R ID: 862970
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1 I certify the applicant is print handica
I certify the applicant is print handicapped as indicated above (Section II). Signature: __________________________________________________________ Date: _____________________________ PLEASE PRINT: Name: _________________________________________ Title: __________________________________ Agency: ___________________________________________________ Phone: ____________________________________ Address: _______________________________________ State: _____ City: ________________ Zip Code: __________ WEYE Seeing Eye Radio of Goodwill Industries of Akron 570 E. W aterloo Road, Akron, Ohio 4431 9 Local: 330-724-6995 Toll-free: 800-989-8428 Fax: 330-786-2513 www.goodwillakron.org Contact: Dave Binkley, Manager, Radio Reading Services Email: dbinkley@goodwillakron.org OODWILL INDUSTRIES ERVING UMMITORTAGEEDINASHLAND ICHLAND OUNTIESRINGING THE Street Address: _________________________________________ City: ___________________________________ State: ________ Zip Code: ___________________ County of Residence: _____________________ Phone: ___________________________________ Name of Nearest Relative/Friend: Relationship: ____________________________ _________________________________________ City: ___________________________________ State: ________ Zip Code: ___________________ ATURE OF PPLICANTANDICAP [ ] Legally Blind: Visual Acuity of 20/200 [ ] Partial Vision: Inability to read standard printed material without special aids or devices other than reading glasses [ ] Physical Handicap: Inability to read or use standard printed material as a result of physical limitations [ ] Reading Disability: Organic dysfunction such as Dyslexia UALIFICATIONPLEASE CHECKApplicant is a recipient of the federally-funded talking book program: [ ] Yes [ ] No PPLICANTIGNATUREApplicants Signature: ___________________________________________ Date: _____________________ OR Person Signing For Applicant Signature: ___________________________________________________