APPLICATION

WHOM SHOULD WE CALL TO PICK UP OR RETURN RECEIVER?
NAME:_
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APPLICATION-- PART ONE
WHIL-RADIO READING SERVICE

PERSONAL INFORMATION WILL BE KEPT CONFIDENTIAL. PLEASE PRINT OR TYPE ALL INFORMATION.

NAME:______________________________________________________________
            (LAST)            (FIRST)           (MIDDLE)

HOME ADDRESS:______________________________________________________
                        (STREET)

      _______________________________________________________________
                  (CITY)            (COUNTY)                (ZIP)

HOME PHONE:________________   WORK PHONE:_______________

DATE OF BIRTH:________________

ARE YOU A VETERAN?      YES________ NO___________

EDUCATION:  CHECK THE HIGHEST LEVEL COMPLETED
      ELEMENTARY_____   HIGH SCHOOL_____
      COLLEGE__________ POST GRADUATE_______

YEARLY HOUSEHOLD INCOME (OPTIONAL)
      0-$20,000______   $20,000-40,000_____     $40,000 AND UP______

PROGRAM GUIDE PREFERENCE: (CHECK ONE PLEASE)
      BRAILLE______     LARGE PRINT______ CASSETTE______

HOW DID YOU LEARN OF THE RADIO READING SERVICE?
      DOCTOR___   RADIO____   TV_____     NEWSPAPER_____
      FAMILY/FRIEND____ REHAB TEACHER____ OTHER_____

CLICK HERE TO CONTINUE. RETURN TO HOME PAGE

APPLICATION

WHOM SHOULD WE CALL TO PICK UP OR RETURN RECEIVER? NAME:___________________________________ PHONE:__________________________________

APPLICATION-- PART ONE WHIL-RADIO READING SERVICE

WHOM SHOULD WE CALL TO PICK UP OR RETURN RECEIVER?
NAME:_
PHONE:

APPLICATION-- PART ONE
WHIL-RADIO READING SERVICE