Date _____________________

Name ______________________________________________________________________________________

Address _____________________________________________________________________________________

City ________________________________ State _____ ZIP _____________

Phone no. (day) (____)________________ (evening) (____) ___________________

County of residence _______________________ SSN _____ - ____ - ________

The following are requested for reporting purposes only .
Birthdate _________________ Race ________________________ Sex M F (circle one)

Are you a resident of a nursing home, retirement home or assisted living center? Y N (circle one)
If so, name ____________________________________________

Would you like to receive program schedules in : print cassette or braille? (circle one)

If I decide to no longer use a receiver provided by TIRS, I agree to return it to TIRS for another’s benefit.
Applicant's signature _______________________________________________________

Receivers cost $100.00. If you cannot afford any or all of this cost, we will do what we can to help you obtain one. Any donation that you make to help offset this would be tax deductible and most appreciated.

Personal reference name: ________________________________________________

Address ______________________________________________

City ________________________________ State _____ ZIP _____________

Phone no. (day) (____)________________ (evening) (____) ___________________
Relationship: ____________________________________________

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For office use only

Date application received _______________________ Date delivered _______________________

Receiver No: _________________________

Notes _______________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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Note: Return the completed application via e-mail to the Triad Information Reading Service at tirs@wfu.edu.

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