Assistive Technology Request Form BEFORE you begin this form, make sure you have added all of the devices (up to 5 at a time) to your ‘loan cart’. If you need to add additional items, continue to browse our inventory. Complete the form below. If you are borrowing equipment for more than one person, please complete a separate request form for EACH person.Your Items:Not finding what you want in our Inventory? Tell us what you are looking for:Contact InformationName(Required) First Last Address(Required) City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip(Required) County(Required)ApacheCochiseCoconinoGilaGrahamGreenleeLa PazMaricopaMohaveNavajoPimaPinalSanta CruzYavapaiYumaPreferred Phone Number(Required)Preferred Phone Is:(Required) Home Cell Work Secondary Phone NumberSecondary Phone Is: Home Cell Work Email(Required) Enter Email Confirm Email What is the best way to contact you if we have questions or need more information about your request(Required) Phone Email Your Request:(Required) I’d like information about this assistive technology I’d like a demonstration of this assistive technology I want to borrow this assistive technology Assistive Technology Professional – Reserve Equipment & Schedule AT Lab Time Please provide several dates/times that you would be available for an assistive technology demonstrationPreferred Dates/TimesPlease provide several dates and time ranges that you would prefer to Reserve Equipment & Schedule AT Lab Time.AzTAP requests 2 full business days prior notice to reserve equipment and the lab. If the lab is booked, the equipment requested is not available or if more time is needed to prepare your request AzTAP staff will contact you. Date #1(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time for Date #1(Required) Morning Afternoon Start Time for Date #1(Required) Hours : Minutes AM PM AM/PM End Time for Date #1(Required) Hours : Minutes AM PM AM/PM Date #2(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time for Date #2(Required) Morning Afternoon Start Time for Date #2(Required) Hours : Minutes AM PM AM/PM End Time for Date #2(Required) Hours : Minutes AM PM AM/PM Date #3(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time for Date #3(Required) Morning Afternoon Start Time for Date #3(Required) Hours : Minutes AM PM AM/PM End Time for Date #3(Required) Hours : Minutes AM PM AM/PM Are you borrowing this assistive technology for your own use or on behalf of someone else?(Required)On Behalf of Someone Else means Not Me (e.g. using for trial with a family member who needs it, a client/patient evaluation or as a loaner for a PWD). For my own use On behalf of someone else What is your relationship to the person who will be using the assistive technology?(Required) Therapist/service provider Family member Friend/neighbor Caregiver/assistant Guardian Employer Other Are you borrowing items/requesting equipment/reserving lab time as a representative of an employer, agency or organization?(Required) No Yes Organization Name(Required) Organization Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code First and last initials of person who will be using the device(s)(Required) County of residence for person who will be using the device(s)(Required)ApacheCochiseCoconinoGilaGrahamGreenleeLa PazMaricopaMohaveNavajoPimaPinalSanta CruzYavapaiYumaHave you previously borrowed from AzTAP(Required) Yes No Disability of person who will be using the assistive technology (check all that are applicable)(Required) Autism/Pervasive Developmental Delay Chronic Health Condition Communication/Speech, Developmental Disability Hearing Related Disability Learning Disability MCS (Multiple Chemical Sensitivity) Mental Illness Multi-Handicapped Neuromuscular Orthopedic/Physical Mobility Traumatic/Acquired Brain Injury Vision Related Disability Other Not applicable (No disability) Age range of person who will be using/benefiting from the assistive technology.(Required)0-23-1112-1819-6566+If "other" please describe:(Required) Purpose of assistive technology loan(Required) For assistance in decision making (for example: to be used during an evaluation or to decide on the most beneficial device for the person who needs the assistive technology To serve as a loaner (for example: to use during repair of an existing device or while waiting for funding) To be used as an accommodation on a short term, temporary basis (for example: borrowing a ramp for a visiting relative who uses a wheelchair) For professional development purposes (for example: to learn more about the device; to use it during a training or presentation) The assistive technology device is needed for:(Required) Education Employment Community Living (Living as independently as possible) Additional Comments/Needs/Requests:What would you like to know?Will you pick up requested item(s) at the AzTAP office or need to have it shipped via FedEx to you?(Required) I will pick up the items at the AzTAP office I would like the items shipped Name of Person who will pick up item(s)(Required) First Last Fax(Required)Ship to Name(Required) Ship to Phone(Required)Shipping Options(Required)NOTE: FedEx offers business and residential deliveries. Additionally, FedEx also offers a “Hold It” option where your loan shipment is held at the nearest participating FedEx location. An email address is required to use this option, since the tracking number (which you will need to pick up the shipment from the FedEx location) will be sent to you by email. For a Hold It FedEx will use the zip code of your ship to address to assign the shipment to the nearest participating location. Once your loan is shipped by us, you can use the FedEx tracking number to change the Hold It location to a different participating FedEx location of your preference. Business Residential Hold It at a Fed Ex Location Address(Required)No PO Boxes Street Address Address Line 2 City State ZIP Code Preferred mode of contact for follow up communication about your loan?(Required) Phone Email Our Standard AzTAP Borrower Agreement is sent electronically via email as a PDF with Adobe Sign. If you require an alternative format, please specify(Required) N/A – No alternative format is needed Large print Braille Audio file Text-Only file Word file An AzTAP staff member will contact you regarding your preference for receiving and signing this agreement.HiddenIf you are requesting an alternative format, please tell us how you would like to receive it. (Note: we are not able to email a Braille document).(Required) By Email By Fax By US Mail PhoneThis field is for validation purposes and should be left unchanged.