SUN SOUNDS OF ARIZONA MEMBERSHIP  APPLICATION (CONFIDENTIAL INFORMATION)
NAME ____________________________________DATE _____________
FACILITY NAME (if applicable) _____________________________
ADDRESS _______________________________________________
CITY ______________________ZIP____________
PHONE ______-________________
BIRTHDATE ____/____/_____
E-MAIL ____________________________________________
Delivery methods (Select at least one. Some methods may not be available
state-wide. Ask your affiliate for details.)
Sun Dial II (telephone) ______ Radio _______ Online________
HD Radio (use your own) ______ Cable TV _______ DTV________

BROADCAST SCHEDULE
Large Print_____Braille_____Audio CD_____Email____

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 $50 replacement fee if the receiver is not returned:

Signature of Responsible Party _______________________________

FOR OFFICE USE ONLY
Delivered _____ Mailed _____ RECV”r# _________ Freq________    DateRet'd____________
2ND#_________Freq__________Rec'd________Ret'd_____________