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CKRE - Listener Application
Central Kentucky Radio Eye, Inc
University Station Box 1030, Lexington, Kentucky 40506-0025
Telephone & Fax: 859-257-2702

LISTENER APPLICATION


PART ONE (To be completed by, or on behalf of, the Listener)

NAME:__________________________________________________________________

ADDRESS:______________________________________________________________

CITY:_________________________ STATE:__________ ZIP CODE:________________

TELEPHONE NO: (________)________________________

DATE OF BIRTH:____________________ SOCIAL SECURITY NO:___________________

I hearby request a CKRE pre-tuned radio receiver. I acknowledge that the radio belongs to and remains the property of CKRE, and is to be returned when I no longer need or want the service. A $25 fully refundable deposit is requested.

SIGNED:____________________________________ DATE:________________________


PART TWO (To be completed by physician, nurse, librarian, or other qualified person who knows the listener's disability)

NAME: (please print) _______________________________________________________

ADDRESS:_______________________________________________________________

CITY:_________________________ STATE:__________ ZIP CODE:________________

PROFESSIONAL CAPACITY:________________________________________________

This is to certify that __(listener)______________________________________________

is unable to read conventional printed material because of the following disability:

________________________________________________________________________

SIGNED:_______________________ DATE:______________ PHONE:______________