Return Application To: 1 Mackworth Island Falmouth, ME 04105

800.639.3884 (V/TTY) 207.766.7111 (Videophone)

207.797.9791 (Fax)

Email Questions To: lpenney@drme.org

www.drme.org

Information About You

TEP Application - Page 1 Rev. 03/16

There are Two Ways to be Eligible for This Program

Income Information

TEP Application - Page 2 Rev. 03/16

Phone Equipment Lending ProgramPlease complete this section only if you are interested in applying for phone equipment. You may receive either a phone or a hearing aid through the lending program; you may not receive both.

Please Select the Option(s) You Are Interested In Not all features are available on all equipment. If there is a feature you must have, please indicate this. The more choices you pick, the more limited your equipment options will be.

Please complete this section only if you are interested in applying for a hearing aid. You may receive either a phone or a hearing aid through the lending program; you may not receive both.

Hearing Aid Lending Program

TEP Application - Page 3 Rev. 03/16

Please Include the Following Documentation with This Application

Proof of Disability *To be Filled Out by a Physician, Audiologist, or Other Medical Specialist*

As a physician, audiologist, or other medical specialist, I certify that the applicant is D/deaf, hard of hearing, late-deafened, has a speech disability, physical disability, intellectual disability, or other medical condition that interferes with his/her ability to use standard telecommunications equipment.

TEP Application - Page 4 Rev. 03/16

Release

TEP Application - Page 5 Rev. 03/16

For DRM Use Only

By signing this application, I agree to abide by the above program requirements and state that all information provided in this application is complete and true.

When You Borrow Equipment Under the Lending Program, You Must

DRM Deaf Services1 Mackworth Island

Falmouth, ME 04105