Arkansas Deaf Community Directory Submission Form

To have your information listed in the Arkansas Deaf Community Directory, complete the form below and submit it to us. By submitting this information, you give AAD full permission to list this information in the Arkansas Deaf Community Directory. Each individual is responsible to notify AAD of any changes of this information. For more information, contact Ira Gerlis at 501-315-9153 or ira.gerlis@arkansas.gov.

By filling out this form, I authorize the information to be printed in the NEXT of the AAD Arkansas Deaf Community Directory and to remain in the Directory until I change or cancel it.

Name: *

Your name.

Spouse Name:

The name of your spouse.

Email Address:

Your email address (ex. you@yoursite.com).

Spouse Email Address:

Address: *

Your street address.

City: *

Your city.

State: * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP: *

TTY:

Your TTY number.

Voice:

Your voice number (if applicable).

Cell Phone/Text:

Cell Phone/Text.

Spouse Cell Phone/Text:

Fax:

Your fax number (if applicable).

Pager:

Your pager number (if applicable).

Video:

Your video phone number or IP address.

Video Brand: - None -Sorenson (black box)D-Link (silver box)Both

Brand of video phone used.

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