Nebraska Specialized Telecommunications Equipment (NSTEP)
Information Request Form

Fill out this form if you would like for the Nebraska Commission for the Deaf and Hard of Hearing to send you an application for Nebraska Specialized Telecommunications Equipment in the mail.

Information received from the submission of forms that are posted on the Nebraska Commission for the Deaf and Hard of Hearing (NCDHH) website, is used for business use only. Information collected through the submission of forms will not be resold for commercial use, all information will be kept confidential.

Entries marked with an * is required information.

Full Name: *

Mailing Address: *

City: *

State: *

Zip Code: *

Phone Number: (include area code)

County: *

E-Mail Address:

Year Born: *

I am:

Deaf Deaf/Blind Speech Impaired Hard of Hearing

I currently use:

Amplifier TTY Other Description of other:

I would like to receive information about the services offered by NCDHH:

Yes No

I would like to receive information about the Nebraska Relay Service:

Yes No

Would you like for your name to be added to the Nebraska Commission for the Deaf and Hard of Hearing's Registry that tracks the number of deaf/hard of hearing people who live in Nebraska? *

Yes No

Thank you for your time in completing this form.