Kansas TAP Telecommunications Access Program (logo)

Application associated with this regional AT Access Site: NE, SE, NC, SC, NW, SW

Return this form to
ATK-TAP
2601 Gabriel
Parsons, KS 67357

800-526-3648
Management at: 866-666-1470
FAX: 620-421-0954
   
Application for Smartphones and Tablets

This application is for a smartphone or a tablet. If you don't want a smartphone or a tablet, please use the Kansas TAP Adapted Phones & Signalers/Accessories Application form.

Personal Information to be completed by applicant.	

Legal name (Last, First, Middle initial): 				
Street Address (P.O. Box not accepted:	
City: 						 
Zip Code: 			 
Email: 					
Home Phone with area code:					 
Date of Birth, include month, day, and year:
Gender:

Alternate Contact Name: 							 
Alternate Contact Phone: 				

Please answer the following yes/no questions.
I am a resident of Kansas:
I have a disability/impairment that interferes with using the telephone:
I have a household gross income that is less than $55,000 per year. $3,000 may be added for each dependent claimed: 
A copy of 1 page from my phone bill with my name and number listed or a copy of the front and back of a prepaid phone card is attached.

NOTE: All of the above statements must be YES for the application to be approved.

(KS TAP reserves the right to request proof of documentation of income. Refusal to provide requested documentation will result in denial of your application.)

I verify under penalty of perjury that the above is true and correct.
Applicant or Guardian Signature: 			
Date:
 			
Demonstration Centers
If you are having trouble deciding, you may call or visit one of the demonstration centers. Please call for appointment.
Western AT Access Site, Northwest Kansas Educational Service Center, 703 West Second Street, Oakley, KS 67748, PHONE: 785-672-3125, FAX: 785-672-3175.
South Central AT Access Site, Southeast Kansas Independent Living, 3033 West Second St. North, Suite 106, Wichita, KS 67203, PHONE: 316-942-5444, FAX: 316-942-3311.
North Central AT Access Site, OCCK, Inc. - Solution Outreach Center, 1605 W. Schilling Rd., PO Box 1160, Salina, KS 67401, PHONE: 785-827-9383, FAX: 785-452-9374. 
Southeast AT Access Site, Southeast Kansas Independent Living, 1714 Main Street, Parsons, KS 67357, PHONE: 620-421-6551, FAX: 620-423-3505.
Northeast AT Access Site, Topeka Resource Center for Independent Living (TILRC), 501 Southwest Jackson St., Topeka, Kansas 66603-3300. PHONE: (785) 233-4572; FAX: (785) 233-1561
Southwest AT Access Site, 302 N. Fleming, Suite 8E, Garden City, KS 67846, CELL (785) 673-9609; PHONE at NKESC: (785) 672-3125. FAX at Western AT Access Site: (785) 672-3175
Prairie Independent Living (PILR-Dodge City), 236 San Jose Drive, PO Box 4, Dodge City, KS 67801, PHONE: 620-371-7690.
Three Rivers Independent Living, 504 Miller Drive, PO Box 408, Wamego, KS 66547, TOLL FREE PHONE: 1-800-555-3994, 785-56-9915, V/TDD.
Prairie Independent Living (PILR), 17 S. Main Street, Hutchinson, KS 67501, PHONE: 1-888-715-6818, PHONE:(620) 663-9920 (TDD).
LINK, 2401 E. 13th Street, Hays, KS 67601, TOLL FREE PHONE: 1-800-569-5926, PHONE:785-625-6942, V/TDD. 
Independence Inc., 2001 Haskell Ave., Lawrence, KS 66046, PHONE: 785-841-0333.

Disability Certification must be completed by one of the following professionals. All information must be completed.

I am a licensed:  		 
Audiologist: 
Physician:
Ophthalmologist:
Optometrist:
Speech Pathologist:
Vocational Rehabilitation Counselor:
Nurse Practitioner:
Physician Assistant:
		
Professional must check the disability/impairment being certified:
Blind or Vision Loss:
Deaf or Hearing Loss:
Hearing and Vision Loss:
Speech Impairment:
Cognitive Impairment*:
Mobility/Motor Impairment*:
*If you marked cognitive or fine motor impairment, please explain why the applicant can't use a traditional phone or mobile device:	

Certifying Authority's Name: 									
State License or Certification Number: 										
Address: 											
Zip Code: 
County:
Phone with area code: 				

Professional's Statement.

I certify that 

(applicant's name) 								

has a disability/impairment that requires specialized telecommunications equipment in order to effectively use the telephone.

Certifying Authority's Signature: 								 
Date: 			

KANSAS TAP APPLICATION - SMARTPHONES & TABLETS  ~ rev. 4-11-2022