Are you a permanent Florida resident? * Yes No I am: * -- Please choose one --DeafDeaf-Blind (dual sensory impaired)Hard of HearingSpeech Impaired or having a speech impairment Means of communication * -- Please choose one --VoiceASL/Sign LanguageAAC AppLip ReadingSpanishTTYOther

For iPhone Applicants

Do you plan to use your existing cell phone plan for service? Yes No Would you like information on a special bundled T-Mobile plan being offered to FTRI clients? Yes No

Choose Your Phone * -- Please choose one --iPhoneiPadiPad (Speech)TruTone Emote Electrolarynx Language * -- Please choose one --EnglishASL/Signed Language I am: * -- Please choose one --DeafDeaf-Blind (dual sensory impaired)Hard of HearingSpeech Impaired or having a speech impairment First Name * Last Name * Phone Number *

In the box below, please enter the primary Email Address you would like to use for your application. This can be your email or the email of a person assisting you with the application process (e.g. family member). This email will be used for important updates during the application process, including requesting additional action and/or information from you. Be sure to periodically check your email, including SPAM/Junk folders, for any emails from customercare@ftri.org.

Primary Email for Important Updates * Street Address * City in Florida * Zip Code * Alternate Contact Name Alternate Contact Relationship Alternate Contact Phone Alternate Contact Email How did you hear about us? * -- Please choose one --Friend / FamilySquareGlow RepresentativeOtherDigital Ad / Social Media / Internet / FacebookDoctor / Hearing Aid Provider / Medical StaffFTRI Event / FTRI PresentationFTRI Website / RDC WebsiteNewspaper Ad / Direct Mail Ad / FTRI Flyer / CouponTV / Streaming Video Ad Do you wear hearing aids? * NoYes Florida Residency Identification Type? * Florida Driver's LicenseVoter IDState ID Residency Identification Number *

Conditions of Acceptance

To receive equipment from the program, you must agree to all of the following conditions:

1. I understand that the equipment I am borrowing for telephone access belongs to FTRI; I do not own it. If I abuse the equipment, I can be held financially responsible for the replacement.
2. I will take good care of the equipment to ensure it is not damaged, stolen, or lost. If it is damaged, stolen or lost, I will contact FTRI immediately at 800-222-3448 (Voice).
3. If the equipment stops working properly, I will not try to fix it. I will notify FTRI at 800-222-3448 (Voice) and they will fix it.
4. I will notify FTRI if my address or telephone number changes.
5. I understand the equipment I receive today must be returned to FTRI if: I move out of Florida, or I no longer need the equipment.
6. I understand that I cannot sell, give away, or loan this equipment to anyone else.
7. I understand that this agreement is binding for any additional or exchanged equipment that I receive from the program.
8. I hereby attest that, to the best of my knowledge, the provided information is true and accurate.
9. I understand my application will not be processed until all required documentation is provided to FTRI.
10. Failure to comply with this COA may result in me being denied participation in the FTRI Distribution Program.
11. By signing this application, I understand that the user of the equipment is responsible for the use and operation of the equipment, and I agree to defend FTRI and release them of any and all claims, damages and expenses arising out of the use or misuse of this equipment by anyone.

Proof of Hearing Loss or Speech Impairment

How would you like to prove hearing loss or speech impairment? Upload documentation

Audiogram, Doctor's note, SLP evaluation. Document verifying hearing or speech loss must be on doctor's letterhead. The applicant's name must be on the documentation.

Provide Doctor / Professional Contact we can contact to obtain your information.

Doctor name is required. "Proof of Hearing Loss or Speech Disability" upload is not required.

IMPORTANT

Please re-check your email address above, to make sure you entered correctly. You will be receiving a confirmation receipt via email if your application is approved. For security and privacy, you cannot make changes after you submit this application. If you need to update your email after submission, you must contact our customer care department by phone or use our instant chat feature to request the change.