Apply for Services – Technology Association for Visually Impaired Missourians (TAVIM)

You should apply with TAP-I for services first. If denied, then you may apply for services with TAVI-MO.

Part 1: Personal Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date of birth? *MM/DD/YYYY)

The following are requirements for requesting adaptive computer equipment through the TAVIM program. If you cannot answer “yes” to all of the following, contact the TAVIM program to discuss a possible referral.

I am a Missouri resident
I have Internet service in my residence.
I have an e-mail address.

My internet service provider is:

My email address is:

I have a computer with

Part 2: Equipment Selection

You will be contacted upon the receipt of this completed and signed TAVIM application form. To assist us in determining the level of support needed during the equipment selection process, please mark all of the following that apply to you.

I have experience using a computer keyboard.
I have experience using a computer.
I know the adaptive computer equipment I need for basic Internet access based on past experience and/or a trial period.
I do not know what adaptive computer equipment I need for basic Internet access.

Part 3: Disability Certification

(To be completed by a licensed physician, speech pathologist, audiologist, hearing instrument specialist or a Missouri Assistive Technology approved agency representative.) Please use the printable form from the PDF version of this document.

Part 4: Applicant Signature and Information Release

Print name and relationship to applicant if someone else completed this form

Phone

Email *

The above facts are true and complete to the best of my knowledge. Upon request, I will provide verification of the information provided. I authorize TAVIM for Internet to release my name, address, and phone number to a consumer support provider.

Signature

Date (MM/DD/YYYY)