Written Proof of Disability Form

Please fill out this form completely and return it to Bookshare® with an original signature from the Certifying Professional (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.

This is not the form for those wishing to have Bookshare verify eligibility directly with the National Library Services for the Blind and Physically Handicapped. For that option, please visit NLS Verification after log in.

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 Member Agreement. If under 18, the Bookshare Member Agreement 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 website.

INSTRUCTIONS

Step 1: Fill out the identifying information about yourself.
Step 2: Print and complete 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 applicant's use of standard print.

Appropriate certifying experts 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 certifying professional. 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 school's Disability Student Services staff may provide certification.

Step 3: Please mail or fax this completed form including the original signature to:

Bookshare Registration
The Benetech Initiative
480 California Ave, Suite 201
Palo Alto, CA 94306-1609
-- OR --

fax: +1 (650) 475-1066

If you have questions, please contact us.

Step 1: Identifying Information.

To be filled out by the Applicant: (All fields are required. Please type or print.)

Name
Address
City
State / Provice / Region
Zip / Postal Code
Country
Email
Date of Birth (if under 18)
School or Group Account Name (if applicable)

Indicate the disability that prevents you from effectively reading standard print:

Visual impairment, including blindness
Learning Disability
Other Physical Disability

Step 2: Print and complete Proof of Disability

Please have this Proof of Disability form 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 applicant's use of standard print.

Appropriate certifying experts may differ for different disabilities. For example, 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, or psychologist with a background in learning disabilities may be the most qualified certifying professional.

To be filled out by Certifying Professional: (please type or print)

I attest, under penalty of perjury, to the physical basis of the visual, perceptual or other physical disability limiting the applicant's ability to effectively use standard print, and that I have the professional qualifications to make such a certification.

Name of Certifying Professional: ______________________________

Title: ______________________________

Organization: ______________________________

Address: ______________________________

City: ______________________________

State/Province/Region: ______________________________

Zip/Postal Code: ______________________________

Country: ______________________________

Daytime Phone Number: ______________________________

Signature: ______________________________ Date: ________________

Step 3

Please mail this completed form, including the original signature of a Certifying Professional, to:

Bookshare Registration
The Benetech Initiative
480 California Avenue, Suite 201
Palo Alto, CA 94306-1609

Fax it to: (650) 475-1066

If you have questions, please contact us.