SUN SOUNDS  APPLICATION (CONFIDENTIAL INFORMATION)
Sun Dial ______     Radio _______     Both________ (no charge)
NAME ____________________________________DATE _____________
FACILITY NAME (if applicable) _____________________________
ADDRESS _______________________________________________
CITY ______________________ZIP____________
PHONE ______-________________
BIRTHDATE ____/____/_____
E-MAIL ____________________________________________
BROADCAST SCHEDULE
Large Print_____Braille_____Cassette Tape_____Disk_____

Description of Disability __________________________________________
NAME and TITLE of verifying authority ___________________________
_______________________________________________________________

Referred by _________________________________

THIS SECTION APPLIES TO SUN SOUNDS RADIO SERVICE ONLY

TWO CONTACT PERSONS, not living with you, must be provided:
These persons may be living outside of Arizona- They will only be contacted
if your mail is returned and you have not notified Sun Sounds of a new
address and phone number.
Name _______________________________ Phone _____-_______________
Name _______________________________ Phone _____-_______________

STATEMENT OF AGREEMENT & RESPONSIBILITY (RADIO SERVICE ONLY)
I understand that the Sun Sounds Radio receiver is on loan to me and
remains the property of Sun Sounds and must be returned when it will no longer be used. I will pay Sun Sounds a $35 replacement fee if the
receiver is not returned:
Signature of Responsible Party _______________________________

FOR OFFICE USE ONLY
Delivered _____ Mailed _____ RECV”r# _________ Freq________ Follow-up________
Assigned by:                                      ___                   Date:                         DateRet'd____________2ND#_________Freq__________Rec'd________Ret'd_______
Received by:                                                                Date: