Authorization for use of APH Federal Quota Order Management System

Login Name (Account):   _____________
Password:  _________________________

Primary contact person for this Federal Quota Account:

Name:________________________________________________________

Address:______________________________________________________

City, State, Zip:________________________________________________

E-mail address:_________________________________________________

Phone:___________________________ Fax:_________________________

Question to be used if password is forgotten: (example:  What is
my favorite color?  Answer:  Red)
Question:_____________________________________________________


Answer:______________________________________________________


Signature of Ex Officio Trustee:_____________________________________

Return to APH: ATTN MARGUERITE ALLEN
APH
PO Box 6085
Louisville, KY 40206-0085

©2004, American Printing House for the Blind, Inc.