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    Book Share Proof of Disability Form

    Uploaded by

    Sojib Sajid
    it's important to know...

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Book Share Proof of Disability Form

    Uploaded by

    Sojib Sajid
    111 views2 pages
    it's important to know...

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    it's important to know...

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    111 views2 pages

    Book Share Proof of Disability Form

    Uploaded by

    Sojib Sajid
    it's important to know...

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Bookshare Individual Membership

    Proof of Disability Form


    Please fill out this form completely and return it to Bookshare with an original signature from the
    Competent Authority (instructions below).

    This form must be received before members can download copyrighted books from Bookshare.
    Written proof of disability is one of the requirements that enables Bookshare to provide access to
    copyrighted materials to individuals with print disabilities as defined in the U.S. federal copyright
    law provision (17 U.S.C. 121) and in our contracts with authors or publishers who have provided
    original digital files. We will notify you by email after we receive your form.

    Note: you also need to complete the registration process, if you have not already done so. If
    over 18, the online process includes consenting to the Bookshare Membership Agreement. If
    under 18, the Member Agreement Form must be signed by your parent or guardian and returned
    to us. This information will only be used in compliance with the terms of our Privacy Policy as
    explained on the Bookshare web site.

    Instructions

    Step 1: Fill out the identifying information about yourself.

    Step 2: Proof of Disability

    Have the Proof of Disability section filled in and signed by a qualified professional in the field of
    disabilities services, education, medicine or psychology. This professional must be a recognized
    expert who attests to the physical basis of the visual, perceptual, or other physical disability that
    limits the applicants use of standard print.

    Appropriate competent authorities may differ for different disabilities. In the case of blindness and
    visual impairments, an appropriate certifier may be a physician, ophthalmologist, or optometrist; in
    the case of a perceptual disability, a neurologist, learning disability specialist (a teacher with this
    type of certification is an example), or psychologist with a background in disabilities may be the
    most qualified competent authority. A social worker with direct knowledge of your circumstances or
    a federal or state agency that maintains registries of qualified people with disabilities for benefits
    purposes may provide certification. If you are a college or university student, your schools
    Disability Student Services staff may provide certification.

    Step 3: Please email this form to Bookshare as an attachment. If it cannot be emailed, you may
    also fax or mail the form.

    [email protected] OR
    FAX: +1 (650) 475-1066
    MAIL: Bookshare
    480 South California Ave., Suite 201
    Palo Alto, CA 94306-1609
    USA

    Please contact us with any questions: http://www.bookshare.org/contactUs


    Bookshare Individual Membership
    Proof of Disability Form
    Step 1 Identifying Information
    All fields are required. Please type or print.

    Member's Information
    Member Name: Sojib Sajid
    Address: 600 Bicetown Road, New York, NY 10007 US
    Phone #:
    Email Address: [email protected]
    Date of Birth: 01/01/1990
    Name of parent or guardian if under 18:

    Step 2 Proof of Disability


    To be filled out by Competent Authority (please type or print)

    Please place an "x" next to any that apply for the above Applicant:
    Visual impairment that prevents effective reading of standard print (blind, legally blind, or with
    other functional vision limitations).
    Severe learning disability that prevents effective reading of standard print.
    Physical disability that prevents reading print or using a print book.

    Competent Authority's Information


    Name:
    Title:
    Organization:
    Address:
    Phone #:
    Email Address:

    I attest, under penalty of perjury, to the physical basis of the visual, perceptual or other physical
    disability limiting the applicants ability to effectively use standard print, and that I have the
    professional qualifications to make such a certification and/or have legal access through my
    organization to existing written documentation attesting to this fact.

    Signature:
    Date:

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