CERTIFICATION FORM:
ELIGIBILITY: To be eligible for this service a person must be unable to utilize
ordinary print because of one or more of the following limitations:
1. Visual acuity of 20/200 or less in the better eye with correction; or,
blurred or double vision after normal correction, as determined by competent
authority.
2. Physical inability to hold a book or turn pages.
3. Visual or physical impairment, extreme weakness or excessive fatigue
preventing reading of printed matter.
Any of the above conditions must be certified by a competent authority, such as
an ophthalmologist, optometrist, medical doctor, social worker, head of
residence, or other competent authority.
I certify that (Mr. Mrs. Ms) ________________________________ has Visual or
physical condition preventing him/her from reading conventional print material.
Signature________________________________
Authority________________________________________
Title:___________________________________________
Address:_________________________________________
________________________________________________
________________________________________________
Phone:________________________
Fax: __________________________
E-mail address _______________________