HOVRS - VRS Equipment Request Form

HOVRS Equipment Application

Eligibility

Thank you for your interest in Hands On VRS. Please take a few minutes to fill out the information below so that we can better serve your needs.

To be eligible to receive VRS equipment:

You must have high-speed internet service
You are Deaf or Hard of Hearing
You communicate using Sign Language

I am requesting: (choose one)

Webcam (PC)

iSight (Mac)

DLink i2eye (Videophone)

Your contact information

Location	homeOffice
First Name	Last Name
Street Address	(P.O. Box Address is not allowed)
City
State
Zip Code
Email Address
Phone Number	TTYVoiceVideophone number
AOL IM Buddy Name

Questions

1. I have a high speed internet.	YesNo
2. I am Deaf or Hard of Hearing.	YesNo
3. I use Sign Language to communicate.	YesNo
4. Do you currently have a VideoPhone, Webcam, or iSight?	YesNo
5. I plan to use the equipment provided by HOVRS to make video relay calls through the Hands On Video Relay Service.	YesNo

About your network connection

Internet Provider	Other
What brand and model is your modem provided by your internet provider?

What type of internet connection do you have?
What type of router do you have?	Other
What is the model number?

If you have a Mac, please answer this section

What is your Mac model?
What version of OS are you using?

Disclaimer, Subscription and Submission

Disclaimer: All equipment remains the property of Hands on Services. Hands On reserves the right to request that the equipment be returned. Hands On reserves the right to turn down any VRS Application for any reason. Hands On reserves the right to verify all information provided on this application.

I certify that all of my answers are true and correct and that I have read and agree with the above disclaimer.

Please check your junk email folder to find our email sent to you.
P.O. Box address is not allowed.

I would like to receive News/Announcement from Hands On VRS.

You may contact us for any questions regarding this form at: http://www.hovrs.com/help

AIM: outreachhovrs

Email: outreach@hovrs.com

VideoPhone: help.hovrs.tv