JOSEPH T. PRINSKE MEMORIAL CCTV FUND APPLICATION
Please complete and return to David Tabak, executive director, by
December 15, 2006 at the address above.
Name: __________________________________________
Address: ________________________________________
City: ____________ State: ___ Zip Code: _______________
Home Phone: _____________________________________
Business Phone: ___________________________________
E-mail: ___________________________________________
Occupation: _______________________________________
Employer/School: ___________________________________
Describe your visual impairment, including acuity: ___________
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Describe how a closed circuit television would aid you in attaining your
personal or professional goals.
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Please indicate family yearly income: $______________
Number of family members residing with you: _________
Please note: Grantee will be asked to permit the Guild for the Blind to use
their image and story in a Guild
publication.
To the best of my knowledge, the information listed above is true and accurate.
_________________________________ Date: __________
Signature
(Note: Letters of recommendation may be requested.)
Please print and mail to:
David J. Tabak, Executive Director
Guild for the Blind
180 N. Michigan Avenue, Suite 1700
Chicago, IL 60601
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