Listener Application – Audio Information Network of Colorado

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Listener Application

Apply Today!

Apply for free programming, services, and equipment by filling out the form below.

If you prefer to fill out a paper application, download and print this version and send to 1700 55th st., Suite A, Boulder, CO, 80301.

Printable Listener Interest Form

Type: pdf Size: 145.14 KB

Listener Application Form

Apply to become an AINC Listener, receive free equipment, and more!

Contact Information
Are you a current AINC volunteer?
- Yes
- No
Interested in signing up to be a volunteer? You are at the wrong form. Sign up to be a volunteer at aincolorado.org/volunteer/ . If you are an existing AINC reader, do not fill out this form to test or listen to programming. Filling out this form when you are not a eligible listener creates errors in our database. DO NOT CONTINUE filling out this form unless you qualify for AINC services. If you have any questions or requests, contact us directly at 303-786-7777.
Name of applicant*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County
Does applicant live in a shared living community?*
- Yes
- No
What is the name of the shared living community?
Phone
Email
Eligibility Requirement
Broadcasts are intended solely for people who have vision loss (blind/visually impaired) or have other limitations which prevent reading standard size print materials (print disabled).
Does the applicant experience vision loss?
- Yes
- No
Does applicant experience another barrier to reading? If yes, please specify in the text box below.
Demographic Information
Funding agencies ask for data on who we serve. AINC provides summaries of this anonymous data only to authorized funders.
Age:*
Please enter a number from 0 to 150.
Sex:
- Male
- Female
Date of Birth*
MM
DD
YYYY
With which ethnic group does applicant most identify as?
Check all that apply.
- American Indian or Alaskan Native
- Native Hawaiian or Pacific Islander
- Caucasian / White
- Asian
- Black / African American
- Hispanic
- I would rather not say.
What is applicant's preferred listening language?
- Spanish
- English
What is the applicants living situation?
- Live alone
- With family and/or friend(s)
- Assisted Living Facility in a shared room (Roommate)
- Assisted Living Facility in a non-shared room (No roommate)
- I would rather not say.
Does applicant live in a female headed household? Is applicant a U.S. Service Veteran?*
Select all that apply.
- Female headed household
- U.S. Service Veteran
- None of these apply
- I would rather not say.
How did you hear about the Audio Information Network of Colorado?
What is the applicant's monthly household income range?
- $1,041 or less
- $1,042 to 1,301
- $1,302 to 1,561
- $1,562 to 1,926
- $1,927 or more
- I would rather not say.
What is the applicant's monthly household income range?
- $1,409 or less
- $1,410 to 1,762
- $1,763 to 2,114
- $2,115 to 2,607
- $2,608 or more
- I would rather not say.
Does applicant have internet access at home?
- Yes
- No
- I'm not sure.
Which listening options are you most interested in?*
- AINC Amazon Echo smart speaker and/or tablet
- Internet through your personal computer, smart phone, or smart speaker
- AINC WiFi Radio for audio broadcast
- AINC pre-tuned digital reciever
- AINC Large Button speakerphone
- Call in using your personal telephone
- I'm not sure.
Which listening options are you most interested in?
- AINC pre-tuned digital reciever
- AINC Large Button speakerphone
- Call in using your personal telephone
- I'm not sure.
What format would applicant like the program schedule in?
Programming schedules and other information may be sent to you periodically. We have several formats that we can send information in. Select all of the formats that are acceptable to you.
- Large print
- Braille
- Audio CD or flashdrive
- Online at website
- I'm not sure.
Want more from AINC?
Stay up to date on AINC news, exciting updates, and opportunities to enter our contests and drawings! Select which method you would prefer us to contact you.
- Email
- Calls
- Large print sent by mail
- Braille sent by mail
- Audio sent by mail
- Opt out of AINC updates (Will still receive important information regarding your service)
Are you an agency representative or caregiver completing this form for someone else?
- I am filling this out for someone else
- I am filling this out for myself
Your name
Person filling out form
First Last
Name of Agency
Your phone number
Person filling out form
AINC's Privacy Policy, Contribution Policy, and Grievance Policy
are available at aincolorado.org/policies-and-documents/
Would you like a copy of these policies sent to you?
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

Audio Information Network of Colorado

(303) 786-7777
ainc@aincolorado.org

1700 55th St, Suite A Boulder CO, 80301 USA

Bringing Print to Life through Audio Broadcasting since 1991

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Copyright © 1991 Audio Information Network of Colorado. All rights reserved.

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