Application for Service

I am applying for: (Choose all you're interested in.) *Dial-in ServiceRadio Reading ServiceIndependent Living Skills Training (mobility, braille, smart phone, etc.)

If you want Radio Reading Service, please choose which device you would like.

Where did you learn about Metropolitan Washington Ear?

Full Name *

Email *

Re-type Email

Primary Phone *

Secondary Phone

Street Address

Apt., suite, etc.

State

Zip

I reside in: *Washington, DCMarylandVirginia

Birth Date

Living ArrangementLive aloneMember of householdAt schoolAt nursing home or retirement home

Name of Home, if applicable.

Please provide alternate contact info in the event we cannot reach you, for equipment maintenance or recovery. *

Choose the media type of instructions for using the services: *TapeLarge PrintEmailmp3 audio

Upload Certificate of Disability (or mail to MWE)

No file chosen

Application for
Dial-in and/or Radio Reading Service

Online Application

Application for Service

Application for Dial-in and/or Radio Reading Service

Online Application

Application for
Dial-in and/or Radio Reading Service