Application for Service and Loan of Radio
Name:
Address:
City:
State:
Zip:
County:
phone:
Email:
Birthdate:
(mm/dd/yyyy)
Gender:
--
Male
Female
# In Household:
Race/Ethnicity:
Send Program Gruides In:
Large Type
Braille
Cassette
Your RIS radio can be connected to your
Comcast cable line at no extra charge.
This ensures clear reception. Are you interested?
Yes
No
Do you want to sign up for our Telephone Dial-in Service?
Yes
No
Do you want to sign up to listen to programs via our web site?
Yes
No
Supply the names, addresses and telephone numbers for two (2) friends or relatives to be contacted if you cannot be reached.
How did you learn about our service?
Doctor
Other Professional
Family/Friend
Presentation
Newspaper, radio, etc.
Other
LOAN AGREEMENT
By checking this box I agree to the following terms:
I will notify Radio Information Service immediately upon moving or changing telephone numbers.
I understand that I am borrowing a receiver from Radio Information Service. It will be my responsibility to return the receiver when I no longer want or need it.
If this receiver is lost, damaged, or stolen, I will reimburse Radio Information Service for its full replacement value.
I understand that the services of RIS come at an annual registration of $40. This fee is subject to change. New listeners enrolling January through June will pay $40 for service in 2007. New listeners enrolling July to December will pay $40 for service in 2007. (To initiate service, please send a check made payable to Radio Information Service. If you cannot afford this fee, please call RIS to apply for a scholarship.)