National Consumer Feedback Network
Registration Form

Today's Date:______/______/_______ (Month / Day / Year)

Name:________________________________

Address:_______________________________

City, State, Zip Code:______________________________

E-mail address:__________________________________

Daytime Phone:(_______)_______________________

Evening Phone:(_______)_______________________

Preferred Reading Medium: (check one)

Regular Print:_____, Large Print:_____, Cassette:_____,
Braille:_____, Electronic (e-mail, disk, etc.):_____.

Are You: (check one)

Legally blind with no usable vision:_____
Legally blind with some usable vision:_____
Not legally blind but visually impaired:_____

Do you have a hearing impairment or are you Deaf?
Yes _______ No _______

Date of Birth: ______/______/_______ (Month / Day / Year)

Age when vision loss occurred:

Are you currently employed? Yes _______ No _______

What is the highest level of education you
have completed? _____________________

Thank you!

Thank you for completing this information. We look forward to working with you in the near future. Please mail this form to the following address.

Consumer Feedback Network
Rehabilitation Research and Training Center
on Blindness and Low Vision
P.O. Drawer 6189
Mississippi State, MS 39762