Application for Free Access to CRIS Programs

I am registered with
I authorize:
To share my contact information with the Connecticut Radio Information System should they need it to update their files.
Authorized Signature
Note: If not registered with either of the above agencies, please have a physician, nurse, physical therapist, social worker or other individual in the allied health field complete the certification.

Certification of Disability
Other
Certifying Authority

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Please Read & Sign this Agreement

I have personally requested access to receive CRIS programs and authorize that this application be signed on my behalf (if necessary.) I authorize the release of medical information that may be required to determine my eligibility to access the programs of the Connecticut Radio Information System.

The radio provided by the Connecticut Radio Information System is on loan to me. Should I no longer need or want the service, I, or someone acting on my behalf, will return the radio to the Connecticut Radio Information System I the shipping box provided.
Signature of Applicant or Authorized Signature
Date

MonthDayYear
Date
Should be Empty:

Personal Information