(Please print) Last --- First --- Initial ------ Date of Birth
INSTITUTION or FACILITY:_________________________________________
ADDRESS:___________________________________ ________ ____________
Street (include room or apt #) --- City ----- State ---- Zip
PHONE: (________) _________ ________________ COUNTY:_____________
Please provide the name, address and phone number of a friend or
relative. Although your Audio-Reader radio is loaned to you for
as long as you need it, it remains our property. We require this
information should it become impossible for us to contact you.
ADDRESS:___________________________________ ________ ____________
Street --- City ------------------ State ---- Zip
PHONE: (________) _________ ________________
CERTIFICATION
This portion of the application should be completed by a physician,
nurse, librarian, social worker. This certification is required
for radio reading services by Federal law.
I certify that the above named applicant cannot read or
effectively use printed materials as a result of the following
condition(s):
__________________________________________________________________
__________________________________________________________________
SIGNATURE ________________________ TITLE _________________________
PHONE: (________) _________ ________________
I have signed on the space below or have personally requested
this service and authorized this application be signed on
my behalf.
X ________________________________ OR ____________________________
I wish to receive the Audio-Reader Program guide in:
BRAILLE ________ LARGE PRINT ________
Please mail completed form to:
Audio-Reader, Box 847, Lawrence, KS 66044-0847
OFFICE USE ONLY:
Manufacturer ___________ Model #___________
Freq.________ Serial #_____________________
Date Sent____________ Ret'd________________