MDTAP AT Service Request

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Thank you for reaching out to the Maryland Assistive Technology Program!

Email *

Name (First & Last) *

Phone Number *

Preferred Method of Contact *

Phone

Videophone

Other:

Required

Is spoken English your primary language of communication? *

Yes

Other:

Do you require translation services? *

Yes

If yes, what translation support can we help provide you with?

Zip Code *

Are you a US Veteran or a family member of a US Veteran? *

Yes

What service are you requesting? *

How would you best describe yourself?
*

Please tell us more about your request:

A copy of your responses will be emailed to the address you provided.

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