AT Demonstration & Loan Program

Suggest an Item for the AT Demonstration and Loan Program Inventory

Directions: Complete this form, providing as much information about the requested product as possible. This information, together with data on frequently requested items, helps us maintain an inventory that responds to the needs of Arizona residents with disabilities and older Arizonans.

Required fields are marked with an *.

Name of Item:
Manufacturer/Vendor:
Description:
How did you hear about this item:
Suggested By:
First Name:
Last Name:
Telephone Number:
Email Address:
AzTAP values your privacy and will not sell or distribute your contact information. This information will ONLY be used to contact you if we have questions regarding your suggestion.

If you wish to print and mail this form, return it to:
AzTAP - Arizona Technology Access Program
Assistive Technology Specialist
Northern Arizona University
300 W. Clarendon Ave, Suite 475
Phoenix, AZ 85013
Fax: 1.866.463.9390