Add Application

Loading...

Application

Information
Equipment
Qualification
Certification
Terms

Assisting Type

I am the applicant.

I am assisting the applicant with completing this form. (If this is checked, please fill out the following additional fields)

Assisting Applicant Information

Relationship to Applicant* (select all that apply).

Family Member (Parent, sibling, child, etc.)

Guardian

Power of Attorney

Equipment Vendor

Other

Name* (First and Last):

Email:

Phone*:

Other Relationship*:

Applicant Information

First Name*:

Middle Initial:

Last Name*:

Date Of Birth*:

Date Format: "MM/DD/YYYY".

SSN(Last 4)*:

Only last four digits of SSN. If the applicant does not have a SSN, please type all zeros. Format as: 0000.

Email*:

Home Phone*:

This Phone Is*:

Alternate Phone:

This Phone Is:

Mailing Address

Street Name*:

Apt/Unit#:

City*:

Zip*:

County*:

Note: If you have questions while completing the application, please contact TAI at the following:
Voice: (515) 282-5099
Toll-Free: (800) 606-5099
Videophone: (515) 207-0776