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Georgia Radio Reading Service, 260 14th Street N.W. Atlanta, Georgia 30318-5360 (404)685-2820
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| Name_____________________________
County____________________________
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| Street Address________________________________________________________
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| City___________________ State______________ Zip________________________ |
| Date of Birth____________ Telephone _____________ Sex: M F |
| Nature of
Disability: ___ 1. Legally Blind ___ 2. Partial Vision -- Inability to read standard printed material without special aids or devices other than regular glasses ___ 3. Physical Handicap -- Inability to read or use standard printed material as a result of physical limitations. ___ 4. Reading Disability -- please specify__________________________________ |
| How did you hear about us?_____________________________________________ |
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| Name of Contact Person________________________ Relationship_____________ |
| Home Telephone __________________ Work Telephone_____________________ |
| Street Address _______________________________________________________ |
| City ________________________ State__________________ Zip_______________ |
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RETURN THIS INFORMATION
TO: GaRRS,
260 14th Street, NW, Atlanta, Georgia, 30318-5360 |
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OFFICE USE
ONLY: Receiver No. _______________ Date:___________ |