Please provide us with your information.
Oregon Telecommunication
Devices Access Program
(TDAP) Application
www.tdap.oregon.gov
PAGE 1
Oregon Public Utility Commission
PO Box 1088, Salem, OR 97308-1088
1-800-848-4442 or 503-373-7171
TTY: 800-648-3458
Videophone: 971-239-5845
Fax: 877-567-1977 or 503-378-6047
Email: puc.rspf@state.or.us
A
SECTION
Name of Applicant (Last, First, Middle) Date of Birth
Parent/Guardian name (if applicant is a minor)
Primary Phone Number Secondary Phone Number
Home Address Apt#
City Zip Code Email address
Mailing Address (if different than above) Apt. # City Zip
Shipping Address (if different than above) Apt. # City Zip
Contact Person’s Name (Last, First, MI) Relationship Phone# Home Cell
Mailing Address of Contact Person Apt. # City Sate Zip
Please provide us with the contact information for someone who can get in touch
with you if we are unable to. If you list a legal guardian or power of attorney
(POA), please provide documentation of the guardianship/POA.
We use your Oregon Driver’s License or ID# to verify that
you live in Oregon. If you do not have an ODL or ID#, please
send a copy of your recent utility bill or benets
statement to us with your application.
Oregon Drivers License or ID#
/ /
( ) - ( ) -
@
( ) -
Required elds are highlighted.
FM608 (Revised 4/26/19)
PAGE 2
Equipment Selection
B
SECTION
If known, please list the model of the device (and optional accessory) you are requesting on the
line below, then proceed to section C.
______________________________________
If you do not know the model, please select either a landline or a wireless cell phone or tablet.
Landline (go to B3) Wireless - Cell Phone or Tablet (go to B4)
B1
HEARING
Corded amplied phone Cordless amplied phone Captioned telephone
Caller ID screen Caller ID screen Landline only
Answering machine Landline & High Speed
Internet
TTY 4425 Voice/Hearing Carry Over phone
Accessory:
Lamp asher Loud ringer Home Aware Kit Hearing aid silhouette (Single)
Headset Neckloop Answering machine Hearing aid silhouette (Dual)
VISION
Corded big-button phone w/
talking keypad/talking caller ID
White buttons
Black buttons
Caller ID screen
Cordless big-button phone w/
talking keypad/talking caller ID
Caller ID screen
COGNITION
Corded phone w/ outgoing
speech amplication
Electrolarynx
SPEECH
Corded phone with
photo-dialing
MOBILITY
Hands-free speakerphone
with remote
Accessory:
Voice dialer
Pillow switch
Air switch
Headset
Lapel microphone
WIRELESS DEVICESALL DISABILITIES
B4
Select a wireless device. You may also select one optional accessory.
iPad
(WiFi Only)
iPad Mini
(WiFi Only)
Android Cell Phone*
Android Tablet*
(WiFi Only)
Accessory:
Bluetooth neck loop
Bluetooth cellular phone amplier
Select a landline device based on your disability and any corresponding feature. You may also
select one optional accessory.
B2
B3
*iPhones and Android cell phones are unlocked and may be used with your preferred cellular provider.
*The applicant is responsible for all service charges associated with the use of the phone.
*For more information about Open Sesame, please visit www.razmobility.com or call us at 1-800-848-4442.
FM608 (Revised 4/26/19)
WIRELESS DEVICES MOBILITY ONLY
Android Tablet
(WiFi Only)
iPhone*
Android Cell Phone*
**The Android tablet and cell phone have Open Sesame
pre-loaded on the device.
Accessory:
Mounting system
Please select one device and one optional accessory.
C
SECTION
Conditions of Acceptance for TDAP Equipment
Please completely READ and SIGN this form indicating that you understand
and agree to comply with the following conditions upon acceptance of all
TDAP Equipment:
All TDAP Equipment (Equipment) provided to me is the property of the State of Oregon, and I will use the
Equipment in compliance with Oregon laws and regulations, including OAR Chapter 860, Division 33.
I am responsible for the appropriate care of all Equipment and the costs related to the use of all Equipment
(Including, but not limited to: batteries and phone or Internet service).
I will not sell, lease, give away, or loan any Equipment to anyone. I will not use any Equipment as collateral for a
loan of any type or as a pledge for a pawn loan.
I am financially responsible for any damage to any Equipment that is not cased by normal wear and tear or acts
of nature or disaster, or if the Equipment is lost.
If floods, storms, fire or other acts of nature damage the Equipment, I will submit a fire, insurance, or other
incident report to TDAP within five (5) business days of the event.
If any Equipment is stolen, I will notify the local law enforcement agency within 24-hours of the the time the theft
is discovered. I will provided a copy of the police report to TDAP within 5 business days of the date the theft was
reported.
I will not attempt to repair any Equipment. If the Equipment is in need of repair, I will contact TDAP. I will return
the defective or damaged Equipment at TDAP's expense. TDAP will repair or replace the returned Equipment at
their discretion. Upon request, TDAP will ship the repaired or replaced Equipment to me.
I will not remove any protective case from the Equipment. I will not damage or deface the Equipment by removing
any property of Oregon identifying labels or alter the laser etching.
I understant that the Equiment may have a web filter installed to prohibit access to websites containing unlawful
content. TDAP and TDAP vendors have my permission to monitor the Equipment to ensure proper use.
If I disconnect my phone service, I will return all Equipment to TDAP within thirty (30) days at TDAP's expense. If
I move to another place in Oregon, I will report my new address to TDAP within thirty (30) days of the move. I will
return all Equipment to TDAP before I permanently move out of Oregon.
I will obtain written permission from the TDAP Manager before I travel out of Oregon with any Equipment for moe
than ninety (90) days.
I will return the Equipment to TDAP within forty-five (45) days of a request from TDAP.
If I have signed this on behalf of a minor or as a guardian for an adult, I agree to notify TDAP about a change in
responsibility within five (5) calendar days of the event (for example, the minor turns 18 or if there is a change of
guardianship).
I understand that I am financially responsible for the replacement cost of all Equipment if I do not comply with any
of the above conditions. I further understand I am financially responsible for any collection costs associated with
failure to pay the replacement cost.
I understand that all Equipment is provided on a first come, first served" basis and its availability is contingent
upon adequate funding.
All statements I have made in this application are
true and correct to the best of my knowledge.
Signature of Applicant or Parent / Guardian (If Applicant is under 18) Date
*Please provide a copy of the Power of Attorney/guardianship documentation if signing on behalf of applicant.
PAGE 3
FM608 (Revised 4/26/19)
D
SECTION
PAGE 4
I have completed Section A and provided all required information.
I have completed Section B and selected the equipment that
meets my needs.
I have signed the Section C Conditions of Acceptance form.
Section D has been completed and signed by a
certifying authority.
Disability Certication
Certifying Authoritys Name (print clearly) Phone Number
State License or Certication Number Email Address
Address
City State Zip
I hereby certify that (applicant’s name) _________________________________________________________________
has a disability that requires specialized equipment to effectively
communicate on the phone.
Certifying Authoritys Signature Date
(Must be original signature, no stamps accepted)
I am a licensed:
Audiologist
Hearing Aid Specialist
Speech-Language Pathologist
Please check the applicant'
s disability(ies)
(Within scope of practice; e.g. a hearing aid specialist certies a hearing loss)
Deaf / Hearing Loss Cognition / Memory Speech
Blind / Vision Loss Mobility / Motor
Certifying Authority Statement
Please have your certifying authority complete this section.
4
CHECKLIST
Vocational Rehabilitation Counselor
Rehabilitation Instructor for the Blind
Licensed Nurse Practitioner
Physician Assistant
Physician
Optometrist
Ophthalmologist
( ) -
@
FM608 (Revised 4/26/19)
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome