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On-Line Application Never mind, take me to the printable FORM Please fill out all of the information below, then click . You should receive immediate confirmation of the information you send. If you need to start over just click the button.
On-Line Application
Never mind, take me to the printable FORM
Please fill out all of the information below, then click . You should receive immediate confirmation of the information you send. If you need to start over just click the button.
NAME
ADDRESS
CITY, ST, ZIP
SOCIAL SEC #
DATE OF BIRTH
E-MAIL
TELEPHONE
sex
IMPAIRMENT(S):
IS THERE A SINGLE PARTY PHONE IN YOUR HOME NOW? No Yes .
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 ATEL (formerly the TDD Program)
. Yes No
Who should we contact to setup an appointment? Please select one:
. Myself at the phone number above Person listed below
I communicate by (check all that apply)
speaking lip reading, and/or sign language sign language only other means
Please mail me a Certificate of Disability Form
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.
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.
Date:
FORM