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. This QuickTalker Freestyle loan includes the following: iPad Air 16GB, Trident 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 StaffDistributor RepresentativeHigher Ed/ProfessorOT/PTParent/Guardian/Family MbrSLPTeacherBusiness 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 webinarPPreviously used the AbleNet product loan programOtherAre you planning on funding this through insurance for a specific individual?*YesNoComments Verification
