Bookshare Individual Membership
Proof of Disability Form
Please complete this form and return it to Bookshare® with the signature of a professional with the
appropriate expertise to determine eligibility (“Professional”).
The Proof of Disability section must be completed and signed by a Professional who attests to the
visual, learning, perceptual, reading or physical disability that limits the applicant’s use of standard
print.
There are many types of Professionals, medical and otherwise, who can complete this form and
their expertise and level of training may differ according to the disabilities being certified. For more
information about qualifications and Professionals who can determine eligibility, please see our
website: [Link]
Where to Send:
Please email the completed form with signature to Bookshare as an attachment. If you are unable
to email the form, you are welcome to fax it to us or send by regular mail.
Email to: membership@[Link]
OR:
FAX: +1 (650) 475-1066
OR:
Send by Postal Mail to:
Bookshare
480 California Ave., Suite 201
Palo Alto, CA 94306-1609
USA
Please contact us with any questions: [Link]
Bookshare Individual Membership
Proof of Disability Form
Step 1 – Member’s Information (Applicant)
All fields are required. Please type or print.
Member's Information
Member Name: Manish Das
Address: 67, Gold Coast Avenue, Streeterville, IL 60610 US
Phone #:
Email Address: mkdjeet@[Link]
Date of Birth: 12/26/1997
Name of parent or guardian if under 18:
Step 2 – Proof of Disability
To be completed by a Professional who can determine eligibility. Please type or print
(please type or print)
Please place an "x" next to any that apply for the above Applicant:
Visual impairment that prevents effective reading of standard print (blind, legally blind, or with
other functional vision limitations).
Learning (perceptual or reading) disability that prevents effective reading of standard print.
Physical disability that prevents reading print or using a print book.
Certifying Professional
Name:
Title:
Organization:
Address:
Phone #:
Email Address:
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 and/or have legal access through my
organization to existing written documentation attesting to this fact.
Professional's Signature
Date:
