IATP – Independent Living Through Technology

>>Please Note: If you have already registered for IATP's online Device Loan program you may login with those credentials to continue.<<

First Name:*		Middle:	Last Name:*
Company / School:			Title:
Address Line 1:*		Address Line 2:
State:*	County:*	City:*	Zip:*
Email:*		Phone Number:*	Alternate Phone:*
Type of Individual or Entity requesting the equipment*		*Two Phone Numbers Must Be Provided*
User Name:*		Password:*
The Demographic information below helps us to better serve our customers and is completely voluntary.
Age Range:	Race:	Disability:	Medicare/Medicaid? Medicare? Kid Care?