Adaptive Technology – Missouri Council of the Blind

Personal Data

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Visual Status

Totally Blind
Legally Blind
Sighted

Membership

Membership Status

Affiliate
Member At Large
None

If an affiliate member, please list which affiliate:

Application Information

Have you previously received a MCB Adaptive Technology grant?

Yes
No

If yes, please list date of award:

Describe previous purchase below:

Grant Amount Requested?

Describe the Adaptive Technology you agree to purchase:

Please indicate your Preferred Vendor:

SUPPORTING DOCUMENTS

The exact specifications of the adaptive technology or computer to be purchased.
A copy of an official price quote from two (2) vendors
Written verification of legal blindness from an Ophthalmologist or other reasonable authority (obtained within the past year) including a description of the applicant’s eye condition, visual acuity and field of vision.

Statement of Agreement

I have read the entire document titled “Missouri Council of the Blind Adaptive Technology Grants Program,” and I understand and agree to all terms and conditions contained therein. All information that I have listed on this application form is accurate to the best of my knowledge and correct to the best of my ability. I understand and agree that any failure on my part to wholly comply with the “Missouri Council of the Blind Adaptive Technology Grants Program” or “Missouri Council of the Blind Adaptive Technology Grants Application Form” may void this application or otherwise render me ineligible for a MCB matching funds grant.

Please submit this appliction electronically and mail supporting documents to:

Send Application and Supporting Documents to:

Missouri Council of the Blind

Adaptive Technology

5453 Chippewa Street

St. Louis, MO 63109