Application Disability Employment and Transitions Vocational Rehabilitation and Blind Services Blind and Low Vision Services (BLVS) ASPIRE Independent Living Youth Transitions Montana Telecommunications Access Program (MTAP) Montana Relay Equipment Applications Other Relay Services Governor's Committee Contact Us Policy and Documents Transportation Disability Determination Services Qualified Sign Language Interpreters Public Comment Contact Disability Employment & Transitions Montana Telecommunications Access Program Application Identifying information Last Name * First Name * Middle Initial Date of Birth: * Please select . . .JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember. . .12345678910111213141516171819202122232425262728293031 year: Phone Number: * E-mail: Are you a resident of Montana: Yes No Physical Address * Number and Street: Town: Zip: Mailing Address (if Different from Physical Address) Number and Street: Town: Zip: Please provide an additional contact person. Name: Contact's Phone Number: Contact's Street Address: Town: Zip: Relationship to applicant: How did you hear about MTAP? Newspaper Story Newspaper Ad Phone Company TV News TV Ad Audiologist Phone Book Friend or family Presentation Internet In the Mail Other Would you like to receive our newsletter? Yes No Qualification Information * Deaf Hard of Hearing Speech Disabled Deaf Blind Visually Disabled and Hard of Hearing Mobility Disabled If mobility disabled, please describe: Is a home visit necessary? Yes No If yes, please tell us the reason: * How many people in your household? * * Total annual houshold income: * What kind of telephone equipment do you need? I need MTAP to determine what equipment would be best. Amplified (louder) Phone Loud Ringer Cochlear Implant Compatible TTY (Text Telephone) and signal device Large Print TTY "CapTel" Captioned Telephone (VCO) Weak Speech Amplified Phone Artificial Larynx "Hands Free" speakerphone (mobility impaired only) I need the folowing specific equipment: Federal Eligibility Are you a: Veteran Federal Employee Retired Federal Employee Native American Verifier Information * Please list a professional who can verify your hearing, speech, or mobility disability. You may not list yourself, a family member, or a relative. You do NOT need to get the verifier's signature. Some examples of people who can be verifiers are: audiologist, hearing aid supplier, doctor, resident manager at a senior community, or any professional who works in the care industry. Name: Telephone Number: Address: Town: Zip: Verifier's occupation (choose one): * Licensed Physician Voc. Rehab. Counselor Audiologist Hearing Aid Dispenser Speech Pathologist Other (Please describe): Application Certification: By clicking the button labeled "Apply Now!", you certify under penalty of the offense of false swearing (Section 45-7-202, MCA), that you meet the definition of Deaf, Deaf/Blind, Hard of Hearing, Speech Disabled, or Mobility Disabled and that all statements made by you in this application are true and correct to the best of your knowledge. You also agree to inform the Montana Telecommunications Access Program (MTAP) of any changes to this information as long as you are receiving services. * I have completed this Application.