Identifying information |
| Last name: |
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| First name: |
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| Middle initial: |
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| Date of Birth: |
year:
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| Phone Number: |
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| E-mail: |
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| Are you a resident of Montana: |
Yes |
No |
Physical Address |
| Number and Street: |
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| Town: |
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| Zip: |
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Mailing Address (if Different from Physical Address) |
| Number and Street: |
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| Town: |
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| Zip: |
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Please provide an additional contact person. |
| Name: |
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| Contact's Phone Number: |
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| Contact's Street Address: |
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| Town: |
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| Zip: |
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| Relationship to applicant: |
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How did you hear about MTAP? |
Newspaper Story
Newspaper Ad
Phone Company
TV News
TV Ad
Audiologist
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Phone Book
Friend or family
Presentation
Internet
In the Mail
Other |
Would you like to receive our newsletter? |
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Yes |
No |
Qualification Information |
Deaf
Hard of Hearing
Speech Disabled
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Deaf Blind
Visually Disabled and Hard of Hearing
Mobility Disabled
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| If mobility disabled, please describe: |
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| Is a home visit necessary? |
Yes |
No |
| If yes, please tell us the reason: |
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| How many people in your household? |
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| Total annual houshold income: |
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What kind of telephone equipment do you need? |
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I need MTAP to determine what equipment would be best. |
Amplified (louder) Phone
Loud Ringer
Cochlear Implant Compatible
TTY (Text Telephone) and signal device |
Large Print TTY
"CapTel" Captioned Telephone (VCO)
Weak Speech Amplified Phone
Artificial Larynx
"Hands Free" speakerphone (mobility impaired only)
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I need the folowing specific equipment: |
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Federal Eligibility |
| Are you a: |
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Veteran
Federal Employee |
Retired Federal Employee
Native American |
Verifier Information |
| Please list a professional who can verify your hearing, speech, or mobility disability. You may not list yourself, a family member, or a relative. You do NOT need to get the verifier's signature. Some examples of people who can be verifiers are: audiologist, hearing aid supplier, doctor, resident manager at a senior community, or any professional who works in the care industry. |
| Name: |
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| Telephone Number: |
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| Address: |
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| Town: |
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| Zip: |
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Verifier's occupation (choose one): |
Licensed Physician
Voc. Rehab. Counselor
Audiologist |
Hearing Aid Dispenser
Speech Pathologist |
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Other (Please describe): |
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Application Certification:
By clicking the button labeled "Apply Now!", you certify under penalty of the offense of false swearing (Section 45-7-202, MCA), that you meet the definition of Deaf, Deaf/Blind, Hard of Hearing, Speech Disabled, or Mobility Disabled and that all statements made by you in this application are true and correct to the best of your knowledge. You also agree to inform the Montana Telecommunications Access Program (MTAP) of any changes to this information as long as you are receiving services. |
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