OGDEN RESOURCE CENTER

Instructional Resource Center for the Visually Impaired

2310 East 13^th Street

Vancouver, Washington 98661-4120

360-696-6321 ext. 183 FAX 360-737-2120 1-800-562-4176 ext. 183

ACCOUNT HOLDER FORM

Application Date:______________

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

o School District Number______ Name____________________________

o ESD Number______ Name____________________________

o Agency (Describe) Name _____________________________________

o WSDS Member Name _____________________________________

o Private Non-parochial Name _____________________________________

2. Individual authorized to provide liaison function between the district/agency and Washington Instructional Resource Center for the Visually Impaired (WIRC):

ACCOUNT HOLDER:*

First Name _________________________________ Middle Initial ___

Last Name _________________________________

Email address __________________________________________________________

Note: Your order confirmations and other IRC communications will go to this address.

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: User name must be unique for each account. If you represent three districts, you will need three accounts, three user names and three passwords.

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: Washington Instructional Resource Center

2310 East 13^th Street

Vancouver, Washington 98661-4120