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Library for the Blind and Print Disabled

Library@blind.state.ia.us

524 4th St Des Moines, IA 50309

515-281-1323

Application for Free Library Service

Iowa Library for the Blind and Print Disabled

To complete filling out this application you will need the name and email of a Certifying authority that can verify your eligibility for our services.   

Certifying Authority Examples:

-Doctor of Medicine 

-Doctor of Osteopathy

-Ophthalmologist

-Nurse

-Therapist

-Professional Staff Member of a hospital, institution, social welfare agency, or library. 

Confidentiality: The information required on this application pertains to eligibility for free library services for the blind and physically impaired individuals. This information is required by the National Library Service for the Blind and Physically Handicapped of the Library of Congress to fulfill the requirements of Public Law 89-522. Complete and accurate information will speed up the application process. All library records, including this application, are considered to be confidential in accordance with the Code of Iowa Chapter 22.7(13).

Full Name

Date of Birth

Full Address

Gender

Additional Information

Contact Person: Person to contact if you can’t be reached or can assist with your account:

Contact Person Name

Contact Person Information

Eligibility Requirements

Certifying Authority Information 

Please list below a doctor of medicine, doctor of osteopathy, ophthalmologist, optometrist, nurse, therapist, or a professional staff member of a hospital, institution, social welfare agency, or a library that can certify your eligibility because of one or more of the reasons above. Qualified library users must be residents of the United States. 

Certifying Authority Information

Facility

Facility Address

Library Services

All books and equipment can be sent and returned through the mail free of charge. Please select below the services you would like to receive. You may check multiple services.

 

Equipment Policy: Playback equipment and special attachments are supplied to eligible persons on extended loan. If this equipment is not being used in conjunction with reading material provided by the Library of Congress and its cooperating libraries, it must be returned to an issuing agency. Your cooperation in returning these items in a timely manner is appreciated.

Services

Optional Equipment

Other Services Offered

Programs for Kids

Choose one option for receiving books

Do we need to exclude books containing the following?

Reading Level

Select the topics you would like to receive

Fiction

Non Fiction

I would prefer catalogs and newsletters in

Additional Topics

How did you learn about the NLS free library service (check up to 3 that apply?)

If you are a PreK-12th Grade Student fill out the following.

If this section doesn't apply to you click next to continue. 

School Address

Teacher/TVI Information