TAP Application

Personal Information

Applicant

Home Address

Mailing Address
(If different from home address)

Miscellaneous Information

Voice TTY Both

Caucasian

African American

Hispanic

Asian

Native American

Other

Sign Language

Speech

Written

Private Insurance

Medicare

Medicaid

No Insurance

Income

Name

Relationship

Name

Relationship

Name

Relationship

History

Have you applied for TAP equipment in the past?

Yes No

If Yes, when?
(Re-application may not be necessary unless your personal situation has changed and/or TAP requests updated information)

Are you an Arkansas Rehabilitation Services client?

Yes No

How did you learn of the TAP program?

Specialized Telephone Equipment

If you request a signaling system, you may be approved to receive one based on your disability. (check one)

Visual Audible Tactile

Deaf

TTY (Teletypewriter)

For sending and receiving typed messages

Hard of Hearing

CapTel Phone

For hard of hearing persons enabling them to use their speech for outgoing calls but receive captioned messages for incoming calls.

Telephone with volume adjustment for incoming voice and louder than normal ringer.

For outgoing spoken message and incoming typed message through a relay service.

Combination text telephone and standard phone allowing for regular calls, TTY calls, voice or hearing carry over calls.

Lightweight cordless phone with volume adjustment for incoming voice.

Amplified phone with caller ID capabilities.

Deaf-Blind

TTY with Braille

For sending and receiving Braille messages.

For persons who are deaf and have severe visual problems.

Speech Impaired

Artificial Larynx

Handheld, portable voice aid for people who have lost use of their larynx. (Specific artificial larynx must be recommended by the person who signs the Eligibility Certificate.)

Telephone or other device to increase the volume of the outgoing voice.

Blind/Vision Impaired

Talking Phone

Telephone that speaks each number as it is pressed and has jumbo sized buttons with Braille.

Mobility Impaired

Hands Free Telephone

Speaker phone with optional headset and/or other special features.

Lightweight cordless telephone with volume adjustment for incoming voice.

Cognitively Impaired

I will need help learning how to use the equipment.

Yes No

I have read and accept the TAP Conditions of Acceptance.