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.
The applicant is or has:
Hard of Hearing
Printed Name of Professional:
REQUIRED TO COMPLETE APPLICATION
State License #
Audiologist/Hearing Aid Specialist
Federal/State Agency Representative
Street Address Line 2
State / Province
Postal / Zip Code
Should be Empty: