Printable Application
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 THOSE REQUESTING A RADIO
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________
___ Date: DateRet'd____________2ND#_________Freq__________Rec'd________
Ret'd________Date:
MAIL OR FAX YOUR APPLICATION TO THE NEAREST OFFICE:
2323 W. 14th Street Tempe, AZ 85281
480-774-8300 Fax: 480-774-8310
7290 E. Broadway, Ste. 166 Tucson, AZ 85710
520-296-2400 Fax:520-298-6676
1300 S. Milton, Ste. 202 Flagstaff, AZ 86001
928-779-1775 Fax:928-226-1387
1929 S. Arizona Ave., #15 Yuma, AZ 85364
928-329-6681 x20
