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 Language * -- Please choose one --EnglishASL/Signed Language What Type of Phone service Do you have? * -- Please choose one --Landline OnlyCellphone onlyBoth landline and Cell PhoneVideophone - SorensonVideophone - ZVRS

I have a problem hearing over the telephone * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I have trouble following the conversation when two or more people are talking at the same time * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always People complain that I turn the TV volume too high * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I have to strain to understand conversations * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I miss hearing some common sounds like the phone or the doorbell ringing * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I have trouble hearing conversations in a noisy background such as a party * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I get confused about where sounds come from * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I misunderstand some words in a sentence and need to ask people to repeat themselves * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I especially have trouble understanding the speech of women and children * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I have worked in noisy environments (assembly lines, jackhammers, jet engines, etc.) * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I hear fine – if people just speak clearly * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always People get annoyed because I misunderstand what they say * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I misunderstand what others are saying and make inappropriate responses * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always I avoid social activities because I cannot hear well and fear I will make improper replies * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always A family member or friend has suggested that maybe I have a hearing problem * -- Please choose one --NeverOccasionallyHalf the timeAlmost Always

Choose Your Phone * -- Please choose one --Clarity Desktop Duo Amplified Telephone with Expansion HandsetClarity Caption Telephone (XLC8GLT Deluxe)GLT Captioning ScreenXLC8 Combo Pack (XLC8 & XLCGo)XLC8 Combo Pack (XLC8 & XLCGo) with Extra HandsetXLC8 Cordless Amplified PhoneXLC8 Cordless Amplified Phone with Extra HandsetXLCGo Smart Phone AmplifierALTO PLUS Corded Amplified PhoneSA-40 Smart Phone AmplifierXLC7BT Cordless Amplified TelephoneAlto Amplified TelephoneCSC500 Amplified TelephoneCSC600 UltraClear Amplifying SpeakerphoneHD-40S Speech Amplified TelephoneCR200 Audio and Visual RingerTR75 Visual Ringer425 TTYBoom Mic Headset AmplifierIn-line Headset AmplifierEarBud Headset AmplifierUA-50 In-Line AmplifierSquareGlow Flasher Do you have a landline phone? * NoYes Do you have a cell phone? * NoYes 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 / FamilyDigital Ad / Social Media / Internet / FacebookSquareGlow RepresentativeFTRI Website / RDC WebsiteOtherDoctor / Hearing Aid Provider / Medical StaffNewspaper Ad / Direct Mail Ad / FTRI Flyer / CouponTV / Streaming Video AdFTRI Event / FTRI Presentation 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.

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.

Before continuing to the next page, have a photo or scan of Voter ID, Driver’s License, or State ID ready to attach.