About Us | Support Us | Programming | Our Productions | Talk to Us
Digital TV | Learning | Community | Events | Search | Home

Monday December 22 2014

Application for SIRIS Radio Placement

First Name:
Last Name:
Street Address
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
Place of Employment:
Please describe the specific medical diagnosis of applicant’s visual/physical handicap

Emergency Contact Information
Phone Number:
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

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
Questions or comments about this page or site?

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.


Copyright © SIU Board of Trustees
All rights to original content reserved.

Managed by Arrow Studio