NAME: ________________________________________
ADDRESS: ____________________________________________
CITY/STATE/ZIP: ________________________________________
PHONE NUMBER: ___________________________________
E-MAIL: _____________________________________________
I hereby apply for the subsidized transportation program referred to as the subsidized cab program sponsored by the American Council of the Blind of Nebraska. I consent to the release of any medical or other information that may be required for the consideration or reconsideration of my application.
Dated this ________________ day of ______________¬__________, 20__________
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SIGNATURE OF APPLICANT
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This portion is to be signed by a medical specialist or counselor of the Nebraska Commission for the Blind and Visually Impaired.
I certify that the above individual is legally blind according to the definitions at the bottom of this page.
________________________________________
Signature
________________________________________
Title
Date: ________________________
LEGAL DEFINITIONS:
1. “Legally blind” - Those whose visual acuity is 20/200 or less in the better eye with correcting glasses, or whose widest diameter of visual field subtends as angular distance or greater than 20 degrees.
2. “Visually disabled” - Those whose visual disability, with corrections and regardless of optical measurement with respect to “legal blindness” are certified as unable to read normal printed material such as the identity of telephone book size characters.
Adapted form 36 C.F.R. 701.10(b)(1),(2).