STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

DEPARTMENT OF HUMAN SERVICES

ADAPTIVE TELEPHONE EQUIPMENT LOAN PROGRAM

C/o Vocational Resources, Inc., 100 Houghton Street, Providence. RI 02940

Telephone (401) 276-0875 (Voice)

                                                        (401`) 861-6677 (TDD)             

 


APPLICATION FORM

 

 

NAME
                        (FIRST)             (MIDDLE INITIAL)                       (LAST)

 

ADDRESS
                                    (STREET)

 




(CITY)                           (STATE)                                    (ZIP)

 

TELEPHONE

 


DATE OF BIRTH                                                  SOCIAL SECURITY# 

                        MO        DAY         YEAR                     


MALE           FEMALE

 

IMPAIRMENT (S): (PLEASE CIRCLE)

             DEAF                                               SPEECH IMPAIRED

             HEARING IMPAIRED                         NON-VERBAL

             DEAF & SIGHT IMPAIRED                 HEARING & SIGHT IMPAIRED

             NEUROMUSCULAR DAMAGE OR DISEASE (SPECIFY BELOW)

 

 

 

 


IS THERE A SINGLE PARTY PHONE IN YOUR HOME NOW?   YES  NO

If the telephone number is not in the applicant’s name, please list the name of the person who is providing the service.

 

 

 


HAVE YOU OR ANYONE IN YOUR HOUSEHOLD BEEN ISSUED ANY EQUIPMENT FROM THE ATEL (FORMALLY THE TDD) PROGRAM?       YES  NO

 

WHO SHOULD WE CONTACT TO SET UP AN APPT?  Please CIRCLE one:
MYSELF AT THE NUMBER LISTED ABOVE        ALTERNATE PERSON BELOW                         

RELATIONSHIP

NAME                                                           TELEPHONE#

 



ADDRESS

 

*Continue to Complete Page 2 Below

 

FOR OFFICE USE ONLY

 

 


Case Number                                                               Date Received

 

 

 

 

 


*PAGE 2

 

 

ARE YOU PHYSICALLY ABLE TO TYPE, IF NECESSARY?         YES      NO

 

DO YOU UNDERSTAND WRITTEN LANGUAGE?             YES      NO

 

I COMMUNICATE BY (CIRCLE ALL THAT APPLY)

 

 SPEAKING     LIP-READING, AND SIGN LANGUAGE

 

 SIGN LANGUAGE ONLY     OTHER

 

 

 

 


I understand that all of this information will be kept confidential and will only be used as required for assistance, reports, and audits.  By sending this form it authorizes the ATEL Program to contact VERIZON to verify telephone service.

I hereby certify that all of the statements made by me on this electronic form are true and correct to the best of my knowledge and belief. As long as I am receiving services, I agree to notify the agency if there is any change of the information furnished on this form.

 

 

 

 


Signature of applicant                                                 Date:

 

 

 

Parent or guardian should sign if under 18 years of age.