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Wednesday April 16 2014


Application for SIRIS Radio Placement

First Name:
Last Name:
Street Address
City:
State
Zip:
County:
Phone:
Date of Birth:
Is this a nursing home or residential care facility?
Name of Facility
Marital Status:
      Spouse Name - First       
      Spouse Name - Last       
Years of Education:
Read Braille?
Hard of Hearing? Yes No
Are you a Books on Tape Subscriber? Yes No
Employed?
Place of Employment:
Please describe the specific medical diagnosis of applicant’s visual/physical handicap


Emergency Contact Information
Name:
Relationship:
Phone Number:
Name:
Relationship:
Phone Number:


Applicant’s Authorization and Agreement:
I have signed on the space below, or have authorized that this application be signed on my behalf. I understand that I will be loaned a radio which is the property of the Southern Illinois Radio Information Service and must be returned when I no longer need the service.
Applicant's Signature:
Person Signing for Applicant:


We request the following information, but it is optional
Ethnicity





How did you hear about the Southern Illinois Radio Information Service?
Annual Household Income:






The WSIU FM News staff is able to accomodate a limited number of public service announcements as first-come, first-served. Announcements scheduled to run as part of the radio program schedule may be purchased very affordably as PSA agreements by contacting Tom Godell at (618) 453-6179.


WSIU Public Broadcasting, Carbondale, Illinois 62901-4306, 618-453-4343
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Southern Illinois University is an equal opportunity employer and will not
discriminate against any person on the basis of race, religion, national
origin or sex in violation of Title VII.

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