User guide

For
Oftice
Use
Only
ii
APPLICATION
for
FTRI
Equipment
Diistrlbution
Program
FIR1
Relay,
Inc.
___--
Section
140
be
completed
by
applicant
Social Security
Number
0
0 0
-
fl
I1
-
[l
fl
n
fl
PLEASE
TYPE
OR
PRINT CLEARLY
C7
C7
-
0
-
0 0
0
Birthdate
3
Volume
Control
Telephone for Hearing Impaired
Cl
Voice Carry-Over Telephone
D
Voice Carry-Over/Hearing Carry-Overl’Text Telephone
D
In-line Amplifier
U
Volume Control Telephone for Speech Impaircd
Ll
Captioned Telephone
Text
Telephone (CapTel)
Name
of
Applicant:
E-mail
0
Audible Ring Signaler
Q
Visual Ring Signaler
First
Name
Middle
Last
Address City
State
Zip
Code
FL
County
Shipping
Add
res
Street
(DO
not
use
P,O.
BOX)
City
State
Zip
Code
Home
Phone
(-)
Work
Phone
(-)
(ifdifferent)
FL
I
certify
that
I
ani
B
Florida
resideni.
who
has
a
hcar.i:ig and:or
spcecli
inipaiinient; the inFormatioli
given
is true.
f
autltorizc
the
certifier
ofthis xpplication
to
ptwide
this
information
10
l-’l’Rl
in
order
that
I
can
receive
the
designated
specialized
telcconim
iiriicat
ioris
equipmeiit.
X
-
Signature
of
Applicant
(If
under
18.
ParenUGuardian) Date Print Name
I
Section
2-to
be
completed
by
the
certifier
NOTE
TO CERTIFIER:
You must sign this application belore
FTRI
can process and approve
it.
Please note that
if
an applicant needs special
equipment not listed
on
this
form,
you must request
the
“Spec,ialized Equipment Supplemental Certification
For”’
from
FTRI.
This equipment
will
not
be
issued without
the
appropriate
forms.
1
certif!. this
:jpplicant
as
(clieck
one)
il
Deaf
D
Hard
of
Hearing
U
DeafiBlind
U
Speech Impaired
111
uccortlancc
with
C’liaptcr
427.705. I’.S..
I
alii
cligihle
to
certif?
FTKI
applications.
!
3m
riian
(chcck
box)
U
Deaf Service Center
U
Licensed Physician
Ll
State Certified Teacher for
Director
3
Sp:ech Pathologist
the Hearing Impaired
U
Hearing Aid Specialist
3
Appropriate State
or
Federal
c)
State Certified Teacher for
P
Audiologist
Agency Rep
the
Visually impaired
Application
must
hc
certified
within
tht.
state
of
I:
oritla.
Certifier‘s Name State License Number
Agency
-
Phone Number
(-)
Address
.-
FL
Certifier’s Signature Date
Certifier’s E-mail
Please Print
Strect
Cit)
State
Zip
Code
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