APPLICATION

I UNDERSTAND THAT I WILL BE ISSUED A WHIL-RADIO READING SERVICE RECEIVER ON AN INDEFINITE LOAN BASIS AND THAT THIS RECEIVER REMAINS THE PROPERTY OF THE WHIL-RADIO READING SERVICE. I UNDERSTAND THAT IT MUST BE RETURNED IF:

 -- THESE BROADCASTS ARE TERMINATED
 --  A CHANGE OF ADDRESS PUTS ME OUT OF SIGNAL RANGE
 --  THE RECEIVER IS NO LONGER BEING USED

FURTHERMORE, I UNDERSTAND THAT IF I AM UNABLE TO RETURN THIS RECEIVER MYSELF, EITHER OF THE TWO PEOPLE LISTED BELOW WILL ASSUME THAT RESPONSIBILITY FOR ME.

______________________________________________________________
 (APPLICANT'S SIGNATURE)  (SIGNATURE OF RELATIVE OR
                               CLOSE FRIEND)

PLEASE PROVIDE THE NAMES AND ADDRESSES OF TWO PEOPLE WHO HAVE AGREED TO ASSUME RESPONSIBILITY FOR RETURNING THE RADIO TO THE WHIL-RADIO READING SERVICE. AT LEAST ONE OF THE ALTERNATES MUST HAVE A DIFFERENT ADDRESS THAN THE APPLICANT. WITHOUT THIS INFORMATION, WE CAN NOT ISSUE THE RECEIVER.

            
NAME:_________________________________RELATIONSHIP:_____________

       ADDRESS:____________________________________________________________

       CITY:_____________________         STATE:___________           ZIP:_____________

       HOME PHONE:___________________            WORK PHONE:___________________
                                   
ALTERNATE #2:

       NAME:_________________________________RELATIONSHIP:_____________

       ADDRESS:____________________________________________________________

       CITY:____________________          STATE:___________           ZIP:____________

       HOME PHONE:__________________             WORK PHONE:___________________