HULL AND DISTRICT TALKING MAGAZINE

                    BLOCK CAPITALS please

                    FIRST NAME..........................................................................................................................................(Mr/Mrs/Miss/Ms)

                    SURNAME............................................................................................................................................................................

                    ADDRESS ............................................................................................................................................................................

                    ...............................................................................................................................................................................................

                    POST CODE...................................                                                       Tel. No...................................................................

                    Date of Birth...................................

                    Please indicate whether: -

                    a) Registered Blind                    □

                    b) Registered Partially-sighted  □

                    c) Not registered (N12)             □                    If the Applicant is not registered blind or partially-sighted, the following

                    declaration must be signed by an Ophthalmologist, Ophthalmic Optician, Doctor or other qualified person.

                    I.....................................................................................................................................................................................Name

    of..................................................................................................................................   ..........................................Address

                    ........................... .............................................................................................................................................Qualifications

                    CERTIFY that the above-named has defective reading vision (generally N12 or worse with spectacles).

                    Signed..................................................................             Date.....................................

    THIS APPLICATION should be sent to: -

                    Registration

                    Hull and District Talking Magazine

                    25 Portland Street   

                     Hull   HU2 8JX