Professional Signature Required
The applicant must receive a signature by their doctor, audiologist, voc rehab counselor, social worker, sign language interpreter, state or federal agency representative, or any other licensed professional in the field of hearing or speech. The professional's signature verifies their have a need for specialized telecommunications equipment to assist communication over the telephone.
I certify that this applicant (type in name below) needs the specialized telecommunications equipment selected.
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The applicant is or has:
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Deaf
Hard of Hearing
Speech Difficulty
Professional Signature
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Date
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/
Month
/
Day
Year
Date
Printed Name of Professional:
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REQUIRED TO COMPLETE APPLICATION
State License #
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Occupation:
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Audiologist/Hearing Aid Specialist
Speech Pathologist
Doctor/Nurse
Federal/State Agency Representative
Teacher
Other
Agency Name
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Phone Number
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-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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