WDET- DRIS Listener Application - Wayne State University

Fields with asterisks (*) are required.

First name *

Last name *

Email *

Date of birth

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Phone number *

Nature of Disability

Gender

Referring Agency Information

Agency name

Agency contact name

Contact person phone number

Applicant must be registered with a Library for the Blind or include a written statement (on letterhead)
from a healthcare professional verifying the presence of a qualifying disability.

Applicant is registered at which library?

If not registered with library, is required statement attached?

Yes

Emergency contact living at a separate address who we may contact if we can’t reach you:

Address *

City *

State *

Zip Code *

Name (first and last name) *

Phone number *

Supporting documentation