This Disability Disclosure form insures that the applicant possesses a
physical limitation that prevents them from reading printed materials.
This document may be signed by: Doctor of Medicine, Osteopathy,
Ophthalmologist, or Optometrist.

This person whose visual disability, with correction and regardless of
optical measurement, is certified by a competent authority as preventing
the reading of standard material, is unable to use standard printed
materials as a result of physical limitations, having a  reading
disability resulting from the natural aging process, a learning
disability, or due to organic  and  environmental dysfunction.
THE DISABILITY MAY BE EITHER TEMPORARY OR PERMANENT.

Print this page and mail or fax to:
Serotek Corporation 
1128 Harmon Place
Suite 310 Minneapolis, MN 55403	Fax: (612) 659-0760

FreedomBox Network Service Application (CONFIDENTIAL INFORMATION)
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Applicant(Customer)Name:_____________________________ Date_____________

Name of Living Facility (If Applicable):_______________________________

Address: ______________________________________ Apt#: _________________

City ___________________________ State: _______________ Zip: __________

Phone: (___) _______________ (REQUIRED EVEN IF UNLISTED)

Date of Birth: ____/____/_____Referred By: ____________________________
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CONTACT PERSON INFORMATION: This person cannot be living with the
applicant. Contact Person may be living outside of your local area. The
contact person will only be contacted if the applicant’s mail is
returned and the applicant has not notified Serotek of a new address and
phone number.

Name: _____________________________________ Phone_____-________________

Ethnic Origin (Requested by Federal Grants) W___ B___ I___ H___ A___
      
Customer Signature_________________________________ Date: _____________ 
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Name of Physician/Competent Authority: ________________________________

Signature: _____________________________________ Phone: (___)-_________

Date___________ Address________________________ Apt#: _________________

City: _________________________ State: __________________ Zip: ________
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FOR OFFICE USE ONLY: Date Posted: _______ RECV'r#: _______ Freq: ______
Date Rec'd: _________ Date Ret'd: _______ 2ND#C'D: _______