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

Application for a Virginia Voice Radio

Listener Application

  • Phone number of person completing application.
  • Email address of person completing application.
  • APPLICANT INFORMATION

  • (Ex: Mr./Mrs./Ms./Miss, Dr./Rev.)
  • Address must include the name of the residential facility and any room, apartment or unit number, if applicable.
  • Only if relevant
    Enter name under which phone is listed when using "Other"
  • ELIGIBILITY

    Virginia Voice services are intended for the use of individuals who are unable to read for themselves due to a vision impairment, or a disability that prevents them from holding printed matter.
  • 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.
  • Primary Contact (Required)

  • (Ex: Mr./Mrs./Ms./Miss/Dr./Rev.)
  • Name of primary contact for the applicant.
  • Only if relevant
  • Please enter complete address for primary contact
  • Second Contact (Desired)

  • (Ex: Mr./Mrs./Ms./Miss/Dr./Rev.)
  • Only if relevant
  • If you have any questions, please contact kwene@virginiavoice.org