NFB NEWSLINE SUBSCRIPTION FORM MAILING ADDRESS: 477 CONNECTICUT BOULEVARD, SUITE 217, EAST HARTFORD, CT 06108 I am registered with a state or private rehabilitation agency for the blind.(*) YesNoInvalid Input If yes, please specify Invalid Input I am enrolled in a public school special education program for the blind or state residential school for the blind.(*) YesNoInvalid Input If yes, please specify Invalid Input I am registered with a cooperating regional library under the program of The National Library Service for the Blind and Physically Handicapped, Library of Congress.(*) YesNoInvalid Input If yes, please specify Invalid Input If you answered no to all the above questions, you must include with this application a letter from one of the following certifying that you are blind, visually impaired, or unable to read newsprint due to a disability. Select One(*) DoctorSocial Security Award LetterPresident of a chapter or affiliate of the NFBTeacher of the visually impairedInvalid Input I would like to receive information in the following format.(*) Large PrintBrailleCDElectronicInvalid Input Your Name(*) Please let us know your name. Address(*) Invalid Input City(*) Invalid Input State(*) Invalid Input Zip Code(*) Invalid Input Telephone(*) Invalid Input Your Email(*) Please let us know your email address. Please enter your initials and the date to certify that your are blind, visually impaired, dyslexic or have a physical disability and are unable to read a printed newspaper.(*) Invalid Input Date(*) Invalid Input