Qwest Center for Customers with Disabilities (CCD)

Application for Exemption from Directory Assistance Charges

Applicant (Disabled Person)
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip Code:
Telephone Number to be Exempt (include area code)
Second Telephone Number to be Exempt (include area code)

Applicant agrees to promptly advise (or cause to be advised) Qwest Corporation if the disability described here ceases to exist.
Signature of Applicant (or person authorized to act on behalf of the Applicant):

Person to Whom Exempt Telephone Number is Billed, if other than Applicant I certify that the Applicant is a full-time resident member of my household. If the Applicant ceases to reside full-time in my household, I will promptly advise Qwest Corporation.
Signature of the person billed for exempt telephone number, if other than the applicant:

SECTION BELOW TO BE COMPLETED ONLY BY THE CERTIFYING AUTHORITY

The Certifying Authority must be a reputable professional whose knowledge and competence under the specific circumstances is generally accepted and acknowledged and/or an authorized employee acting for and on behalf of a special school, institution, or other recognized entity whose knowledge and competence under the specific circumstance is generally accepted and acknowledged.

The Applicant is: (See definitions below):

Blind
Physically Disabled (describe below)
Visually Disabled
Reading/Mentally Disabled (describe below)

Disability Description:

I certify that the Applicant has the above disability that prevents them from using a telephone directory and/or from completing telephone calls.

Signature of Certifying Authority:
Printed name of Certifying Authority:
Title and Agency:
Date:

The facts in this application may be reviewed periodically by Qwest Corporation

For Qwest Use Only

Order Number

Issued By

Return Completed Application to:
Qwest's Center for Customers with Disabilities
P.O. Box 2670
Omaha, NE 68103

Voice/TTY: 1 800-223-3131
Fax: 1 866-826-4839