Application Page 2
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MTBL Homepage: http://msl.mt.gov/talking_book_library

ELIGIBILITY AND CERTIFICATION REQUIREMENTS: In cases of BLINDNESS, LOW VISION OR PHYSICAL HANDICAP, you must be certified by a "competent authority:" Defined as a doctor of medicine (M.D.), doctor of osteopathy (D.O.), OR ANY OF THE FOLLOWING: ophthalmologist, optometrist, registered nurse, therapist, professional staff of a hospital, institution, and public or welfare agency (e.g. social worker, counselor, rehabilitation teacher and superintendent), or by any person whose competence under specific circumstances is acceptable to the Library of Congress.

TO BE COMPLETED BY CERTIFYING AUTHORITY:

I certify that the applicant named below is unable to read or use standard printed materials for the reason(s) indicated below:

___BLINDNESS: Visual acuity of 20/200 or less in the better eye with correcting glasses, or the widest diameter of visual field subtending an angular distance no greater than 20 degrees.

___LOW VISION: Inability to read standard printed material without aids or devices other than regular glasses.

___PHYSICAL HANDICAP: Inability to read or use standard printed material due to physical limitations, e.g. paralysis, missing arms or hands, extreme weakness.

In cases of READING DISABILITY (see below) from "organic dysfunction," you must be certified by a "competent authority;" Defined ONLY as a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.), who may consult with colleagues in associated disciplines.

___READING DISABILITY: Organic dysfunction of sufficient severity as to prevent reading printed material in normal manner.

Requires a signature certification by an M.D. or D.O. as defined above.

**TO BE SIGNED AND COMPLETED BY CERTIFYING AUTHORITY:

____________________________________________________________________________
Signature of Certifying Authority Please Print Name

Title:_________________________ Phone:_____________ Date:______

Address:______________________________________________
(Street or PO Box) (City) (State) (Zip)

**NOTE: An original signature by the certifying authority is required for certification. Faxes or copies of the certification are NOT acceptable.