Listener Application Form

Please complete all information to avoid delays in service.

First Name:*

Last Name:*

Address:*

Address:

City:*

State:*

Zip:*

Phone:*

( ) - -

Email:

Birth Date:*

Gender:*

Male Female

Nature of Disability:*

Referring Agency or How did you learn of DRIS?

Applicant must already be registered with a Library for the Blind and Physically Handicapped or submit a written statement from a healthcare professional verifying the presence of a qualifying disability. Please refer to the Application Process for additional information.

Applicant is registered with which library service:

If not registered with a library, is required statement attached: Yes No

First Name:*

Last Name:*

Address:*

Address:

City:*

State:*

Zip:*

Daytime Phone:*

( ) - -

Relationship:*

Evening Phone:*

( ) - -

I will use DRIS on the Internet
I would like to borrow a closed-circuit radio receiver

The above information is complete and accurate. I am requesting the DRIS service for my personal use. If a radio receiver is loaned to me, I agree to ensure its safe return when I discontinue listening or move away from the broadcast area. If the receiver should become lost or seriously damaged beyond reasonable wear and tear, I will accept financial responsibility for its replacement.

DRIS is a nonprofit service that depends on donations to operate. A voluntary fee of $50 is requested from listeners annually to help defray operating costs. Please make all checks or money orders payable to:WSU/DRIS #4-44697.

Please note that an inability to contribute will not affect eligibility or service. If you enjoy using DRIS and cannot contribute, we encourage you to ask a relative or friend.

Detroit Radio Information Service
c/o WDET FM
4600 Cass Avenue
Detroit, MI 48201
Outreach Office (313) 577-4207 -- Fax: (313) 577-1300
DRIS@wayne.edu

Listener Application Form

Wayne State University

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