The following application should be completed and submitted by an authorizing agency or person. If you have any questions, please e-mail us.



Applicant's Name
  (first, middle initial, last)
Address Line 1:
Address Line 2:
City:
State:
ZIP (5- or 9-digit):
Applicant's E-mail Address (Optional):
Home Phone (with Area Code):
Work Phone (with Area Code):
  Applicant is a Talking Book subscriber

When we set up your new account, we will provide you with a packet of information. This packet will include your user ID and password, along with instructions to get you started so that you can quickly begin to enjoy the Telephone Reader experience.

We offer this information in several different accessible formats. Please indicate below which format you prefer. If you choose e-mail, be sure you have provided us with your e-mail address above!

 

This portion of the app should be completed by a physician, nurse, librarian, social worker, etc.

I certify that the above named applicant cannot read or effectively use printed materials as a result of the following physical condition(s):

 
Name:
Agency or Service Provider:
Title:
E-mail address:
Phone:
Comments:
 

When you are satisfied that all the information above is correct, click the SUBMIT button below. Thanks for your interest in the Air Capital Telephone Reader!