395 Azalea Avenue (Mailing Address: PO Box 15546) Richmond, VA 23227 | 804-266-2477

Application for a Virginia Voice Radio

Listener Application

  • Best phone number for person completing application.
  • Best email address for person completing application.
  • APPLICANT INFORMATION

  • (Mr./Mrs./Ms./Miss)
  • Address must include the name of the residential facility and any room, apartment or unit number, if applicable.
  • Nearest Relative or Friend (may be at same address as applicant)

  • Title of first contact (Mr./Mrs./Ms./Miss)
  • Name of first contact for the applicant.
  • Complete address for contact 1
  • Best email address for contact 1
  • Home phone number for contact 1
  • Cell phone number for contact 1
  • Another Relative or Friend (not at same address)

  • Title of second contact (Mr./Mrs./Ms./Miss)
  • Name of second contact for the applicant.
  • Complete address for contact 2.
  • Best email address for contact 2
  • Home phone number for contact 2.
  • Cell phone number for contact 2.
  • ELIGIBILITY

    Virginia Voice programming is intended for the use of individuals who are unable to read for themselves due to vision impairment or other disability.
  • The above-named applicant is eligible for a Virginia Voice radio for the following reason(s):
  • Please provide diagnosis or details of health condition and/or disability.