TAI Equipment Vendor Information Form
Business Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your location have multiple locations?
Yes
No
Additional location information
*
EIN#
*
Employer Identification Number / Federal Tax Identification Number
Primary Contact Person
Telephone # (Voice)
*
Please enter a valid phone number.
Telephone # (TTY)
Please enter a valid phone number.
Telephone # (Toll-Free)
Please enter a valid phone number.
Videophone Number
Please enter a valid phone number.
Email
*
example@example.com
Website
*
If you do not have one, please write n/a
Telecommunications Access Iowa requires Dealers offer a wide variety of telephone (telecommunications equipment) from which Voucher Recipients can choose to meet their specific communication needs. Please check each line verifying the categories of telephones/devices offered through your organization:
*
Amplified Phones
Captioned Phones
Speech Amplified Phones
Electrolarynx Telephone Kit
Text Phones (TTY)
Flashing/Loud Ringers
Headset or Neckloop
Amplified Answering Machines
Speech Therapy Devices
Other
Do you repair telephone equipment?
*
Yes
No
Please write in the box below to share any other information you have.
Submit
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