Professional Signature Required
An applicant needs your verification that they are Deaf, Hard of Hearing, or have speech difficulty. Please complete the form with your information below and submit to us.
Applicant's Name
*
First Name
Last Name
I, the professional, certify that the applicant above needs aspecialized telecommunications equipment because they are or has:
*
Deaf
Hard of Hearing
Speech Difficulty
Name of Professional
*
Add titles if neccessary
State License #
*
Required to complete application
Signature of Professional
*
Signature of Professional Date
*
-
Month
-
Day
Year
Date
Professional Occupation
*
Audiologist/Hearing Aid Specialist
Speech Pathologist
Doctor/Nurse
Federal/State Agency Representative
Teacher
Other
Professional Information
*
Agency Name
Agency Address
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Professional Email
example@example.com
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