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Listener Application for Service
Listener Contact Information
Name
*
First Name
Last Name
Email
Verify Email
Phone
*
Institution/Facility
If applicable
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Birthday
*
(mm/dd/yyyy)
Services
How can we support you?
What services are you applying for?
*
Select all that you are interested in.
Radio
Telephone Reader
Internet Streaming & Alexa
Special Request
Audio Description
How would you like to receive your quarterly program guide?
*
Braille
Large Print
Email
Certifying Authority
Please let us know the person or organization who referred you.
Name
First Name
Last Name
Title/Relationship to Applicant
Phone
Conditions
*
Blindness
Diabetic Retinopathy
Dyslexia
Glaucoma
Low Vision
Macular Degeneration
Physical Limitation
Other
Where did you hear about Audio-Reader?
Medical Practitioner
Health or Senior Fair
Friend or Family Member
Veterans' Organization
IAAIS Website
Radio or Print Advertisement
Facebook, Twitter or other Social Media
Senior Resource Center
Lions
Public Library
Assisted Living Facility Staff
Other Service Provider
Internet Search
