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Disability Indicator Form

  1. Life Support System

  2. Speech Impaired

  3. Deaf or Hard of Hearing

  4. Blind

  5. Mobility Impaired

  6. Cognitive Impairment

  7. TTY

  8. By initiating this document I understand that I am responsible for notifying my 9-1-1 Municipal Coordinator of any changes with regard to the status of the above disability indicator(s). I further agree, I will indemnify, defend and hold the State 911 Department, Verizon, my public safety dispatch location and municipality harmless from and against any claims, suits and proceedings (including attorney fees associated therewith) resulting from or arising out of the initial provision or updating of this information.

  9. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  11. This field is not part of the form submission.