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Assistive Technology Request Form

Assistive Technology Request Formwebmaster2022-08-24T07:57:04-07:00

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.

Contact Information

Name(Required)
Preferred Phone Is:(Required)
Secondary Phone Is:
Email(Required)
What is the best way to contact you if we have questions or need more information about your request(Required)
Your Request:(Required)
Please provide several dates/times that you would be available for an assistive technology demonstration

Preferred Dates/Times

Please 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)
Time for Date #1(Required)
Start Time for Date #1(Required)
:
End Time for Date #1(Required)
:
Date #2(Required)
Time for Date #2(Required)
Start Time for Date #2(Required)
:
End Time for Date #2(Required)
:
Date #3(Required)
Time for Date #3(Required)
Start Time for Date #3(Required)
:
End Time for Date #3(Required)
:
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).
What is your relationship to the person who will be using the assistive technology?(Required)

Are you borrowing items/requesting equipment/reserving lab time as a representative of an employer, agency or organization?(Required)
Organization Address(Required)
Have you previously borrowed from AzTAP(Required)
Disability of person who will be using the assistive technology (check all that are applicable)(Required)
Purpose of assistive technology loan(Required)
The assistive technology device is needed for:(Required)
Will you pick up requested item(s) at the AzTAP office or need to have it shipped via FedEx to you?(Required)
Ship to the same address?
Name of Person who will pick up item(s)(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.
Address(Required)
No PO Boxes
Preferred mode of contact for follow up communication about your loan?(Required)
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)
An AzTAP staff member will contact you regarding your preference for receiving and signing this agreement.
Hidden
If 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)
This field is for validation purposes and should be left unchanged.

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The Arizona Technology Access Program (AzTAP)
Northern Arizona University
300 W. Clarendon Ave, Suite 475
Phoenix, AZ 85013
602-728-9534
Fax: 866-463-9390
Toll-Free: 1-800-477-9921
NAU Northern Arizona University Institute for Human Development
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