Directory Registration Form

Is this an update?

Yes (if Yes, please fill in ALL of the information below, as we will delete your current listing and replace it with this information) leave blank if this is a new listing

If this is an update, what state/country is your current listing located? Select One (Required) International - Australia International - Canada International - England International - Germany International - Israel International - New Zealand International - Sweden US - Alaska US - Alabama US - Arkansas US - Arizona US - California US - Colorado US - Connecticut US - Delaware US - Florida US - Georgia US - Hawaii US - Idaho US - Illinois US - Indiana US - Iowa US - Kansas US - Louisiana US - Maine US - Massachusetts US - Maryland US - Michigan US - Minnesota US - Missouri US - Mississippi US - Montana US - Nebraska US - Nevada US - New Hampshire US - New Jersey US - New Mexico US - New York US - North Carolina US - North Dakota US - Ohio US - Oklahoma US - Oregon US - Pennsylvania US - South Carolina US - South Dakota US - Tennessee US - Texas US - Utah US - Virginia US - Washington US - West Virginia US - Wisconsin US - Wyoming

Name: (Last, First - entry must be in this order)

Agency:

Email Address:

Business Phone: (xxx-yyy-zzzz)

Fax: (xxx-yyy-zzzz)

Area in which you wish to have your information listed:
Select one Braille Transcriber Deafblind Early Childhood Ed Rehabilitation Vision

Important! You must select which type of listing you want - otherwise you will be listed under the General listing. General listings are a free courtesy, while Business Card listings carry a nominal fee, but give you maximum visibility.

Listing type:
General listing
Business Card listing (by selecting this option, you will be included in the general listings and we will also contact you with information on a Business Card listing)

Please Note: Due to the high cost of maintaining space on our server, we are no longer able to list any "additional information" with your courtesy listing. Should you wish to have any expanded information, such as vita, additional areas of expertise, etc., listed you might wish to check the Business Card listing above. For a very nominal annual fee your information will not only be listed within the general listings, but will also be included on a separate, very distinct, page.

Please check all of the qualifications that you have:

Orientation and Mobility Specialist
Teacher of the Visually Impaired
Rehabilitation Teacher
Low Vision Rehabilitation Specialist
Deafblind Specialist
Early Childhood Education
Rehabilitation Specialist
AER/ACVREP Certified
AER/ACVREP Certifiable
Agency Trained
Library of Congress (Braille Transcribers only)

University or Agency Where Training Received:

Interested in employment opportunities
Student - Estimated Graduation Date:

To enable searching by geographical region, please supply your state, or country if outside the US: Select One (Required) International - Australia International - Canada International - England International - Germany International - Israel International - New Zealand International - Sweden US - Alaska US - Alabama US - Arkansas US - Arizona US - California US - Colorado US - Connecticut US - Delaware US - Florida US - Georgia US - Hawaii US - Idaho US - Illinois US - Indiana US - Iowa US - Kansas US - Louisiana US - Maine US - Massachusetts US - Maryland US - Michigan US - Minnesota US - Missouri US - Mississippi US - Montana US - Nebraska US - Nevada US - New Hampshire US - New Jersey US - New Mexico US - New York US - North Carolina US - North Dakota US - Ohio US - Oklahoma US - Oregon US - Pennsylvania US - South Carolina US - South Dakota US - Tennessee US - Texas US - Utah US - Virginia US - Washington US - West Virginia US - Wisconsin US - Wyoming

Please Note:  Using this form to submit information NOT related to the field of special education will be considered THEFT OF SERVICE, and the submitter will be turned over to the NC Attorney General for legal action.