QuickTalker Freestyle Loan Request QuickTalker Freestyle Loan Request Please complete the following form to initiate the AbleNet Product Loan process. Follow-up contact will be initiated by our support staff within 24-hours of submission. The loan product will be shipped to you at no cost. You are required to ship the product back to AbleNet 14-days after receipt of the product. (Return shipping is included free of charge.) This QuickTalker Freestyle loan includes the following: iPad with 9.7” screen, protective case with carrying handle, 6 AAC Apps (Proloquo2Go, TouchChat HD AAC with WordPower, GoTalk Now, LAMP, Speak for Yourself, SoundingBoard), Sound Amplifier, Wall Plug, Blue2 Bluetooth Switch, Hook+ Switch Interface, 2 Jelly Bean Twists. First Name*Last Name*Email Address* Phone*Title*AdministratorATClinician / Support StaffCurriculum SpecialistDistributor RepresentativeHigher Education / ProfessorOT / PTParent / Guardian / Care GiverSLPTeacherBusiness Type*College/UniversityDistributorHome SettingHospital/Rehab Ctr/ClinicPrivate PracticeResource CenterSchoolCompany/School NameShip to Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about the AbleNet product loan program?*Online Search – Google, Bing, Yahoo!, etcSocial Media – Facebook, LinkedIn, Twitter, etc.AbleNet WebsiteEmail from AbleNetReferral from a colleague or friendI contacted AbleNet and someone told me about itMeeting with an AbleNet team memberAt a conferenceAbleNet catalogAbleNet University webinarPreviously used the AbleNet product loan programOtherAre you planning on funding this through insurance for a specific individual?*YesNoCommentsPolicy Update*By clicking Submit, you agree to our Privacy Policy & Terms of Use. Links to Privacy Policy & Terms of Use available below. I agree Verification Privacy Policy & Terms of Use
