Audio Reading Service

Fields marked with * are required

Organization

Organization Name *

Type of Organization *

Staff Representing Organization

First Name *

Last Name *

Position Title *

Address

Street Address *

Address Line 2

City *

State *

Zip *

Primary Phone *

Secondary Phone

Email *

Secondary Representative (Optional)

First Name

Last Name

Position Title

Phone

Tertiary Representative (Optional)

First Name

Last Name

Position Title

Phone

I am requesting individual radios for my organization.

How many radios are you requesting? *

My hospital provides a system-wide signal.

Number of Licensed Beds:

My long-term facility/retirement community provides a system-wide signal.

Number of Residential Units:

How did you learn about the Audio Reading Service? *

STATEMENT OF AGREEMENT AND RESPONSIBILITY

I understand that the Audio Reading Service programming is intended solely for individuals who are visually impaired or have other reading challenges, and may not be broadcast or redistributed without the consent of the Audio Reading Service. As an individual listener and/or authorized contact, any radio mailed to me by the Audio Reading Service is on loan from and remains the property of the Allen County Public Library. I agree that I, my authorized contact, or other responsible persons will return the radio when no longer in use, by mailing to the Audio Reading Service at 7615 DiSalle Blvd., Fort Wayne IN 46825 or by dropping it off at any branch of the Allen County Public Library, with my name and reason for return included.

Staff Signature *

I have read and agree to statement terms *

To return or request replacement - take radio to any Allen County Public Library branch, staff will forward to the Audio Reading Service. Be Sure to include your name, address and reason for return. If a replacement radio is needed please include a note to let us know. Thank you!

APPLICATION FOR AUDIO READING SERVICE FOR ORGANIZATIONS