Ogden Resource Center

formerly Instructional Resource Center &

Braille Access Centers

Washington State School for the Blind

2310 East 13th St.

Vancouver, WA 98661

www.wssb.wa.gov/irc/welcome.aspx            1-800-562-4176 x. 183

360-696-6321 x. 183              irc@wssb.wa.gov

 

 
                                                                                    

 


 ACCOUNT HOLDER REGISTRATION FORM

 

Application Date:______________

 

1.     Account Type:  Select one of the five boxes and complete the information for that selection.

        o   School District              Name________________________ Number______ 

        o   ESD                            Number______ 

o   Agency (Describe)                Name _____________________________________

        o   Private Non-parochial   Name _____________________________________

 

2.     Individual authorized to provide liaison function between the district/agency and Ogden Resource Center at WSSB.

 

ACCOUNT HOLDER:*

First Name _________________________________ Middle Initial ___

Last Name _________________________________

Email address __________________________________________________________

Note: Your order confirmations and other ORC communications will go to this e-mail.

 

Title (select best category below)

o Teacher

o Parapro

o Administrator

o Parent

o Other_____________

 

Phone (__ __ __) __ __ __-__ __ __ __    FAX (__ __ __) __ __ __-__ __ __ __  

 

*Account Holder Signature ________________________________________________

(Continued on back of form)

3. User Name __________________________  Password  ____________________

Note: Please choose your own User Name and Password.

 

4. First Mailing Address (Where correspondence with Account Holder will be mailed)

 

Organization ______________________________________________________

 

Address 1 ________________________________________________________

 

Address 2 ________________________________________________________

 

City ________________________ State __ __  Zip __ __ __ __ __ - __ __ __ __

 

Attention __________________________________________________________

 

 

5.     Signature of Superintendent, Director of Special Education, or agency administrator authorizing the above designation*. (Only if the account holder is not the Superintendent, Director of Special Education, or agency administrator.)

 

        Signature _________________________________________________________

 

        Printed Name  _____________________________________________________

 

        Title __________________________________   Date _____________________

 

 

* Superintendent, agency administrator, Director of Special Education or other administrator who has authority for the program for students who are visually impaired and who would cause the requested non-consumable items to be accounted for and eventually returned. Only one account holder per district/agency.

 

Return this form to:    Ogden Resource Center

                                Washington State School for the Blind

                                2310 East 13th Street

                                Vancouver, Washington 98661-4120

 

Upon receipt of this form ORC staff will set-up your account and e-mail you when open.