Qwest Center for Customers with Disabilities (CCD)

Applicant

To be completed by the disabled person:

Full Name of Disabled Person:

Social Security Number of Disabled Person:

Address:

City:

State:

Zip Code:

Area Code/Telephone Number:

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):

Printed Applicant Name:

Person to Whom Telephone Number is Billed, if other than Applicant:

Full Name of Person Applying for credit:

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 Person to Whom Telephone Number is Billed, if other than the Applicant:

Printed Applicant Name:

Select whether you will lease or purchase the equipment:

Lease
Purchase

Check item(s) needed and color if appropriate:

Volume Control –Hearing Handset - Square earpiece and mouthpiece (Only available in Ivory)

Volume Control –Hearing Handset - Round earpiece and mouthpiece Select desired color for handset Ivory Black White

TTY (Telecommunications device for the deaf)

Adjunct Volume Control

Headset

THIS SECTION TO BE COMPLETED ONLY BY THE CERTIFYING AUTHORITY

Qualified Certifying Authorities include doctors of medicine, osteopathy, and ophthalmology; registered nurses, therapists, and professional staff of hospitals and public welfare agencies; and other recognized professionals whose competence under specific circumstances is generally accepted.

I certify that the Disabled Person has a disability, indicated and described below which prevents conventional use of telephone service.

Visually Disabled
Physically Disabled
Hearing Disabled
Cognitively Disabled

Signature of Certifying Authority:

Title of Agency:

Date:

The facts in this Application and Certification may be reviewed and confirmed periodically be Qwest Corporation

Qwest Corporation will contact you to confirm receipt of your application.
The company may request a renewal application at the end of a two-year period (which may NOT require re-certification).

Definitions of Visually, Hearing, Physically, and Cognitively Disabled

The Certifying Authority must certify one or more of the following:

Visually Disabled -- The Applicant is “Visually Disabled” if even with correction and regardless of optical measurements, the Applicant is unable to read standard printed materials.

Hearing Disabled -- The Applicant is “Hearing Disabled” if the Applicant has limited hearing ability, ranging from the inability to hear environmental sounds to not understanding speech on the phone, even with the help of a hearing aid.

Physically Disabled -- The Applicant is “Physically Disabled” if the Applicant is unable to hear or is unable to use standard telephony equipment due to physical limitations, such as but not limited to, loss of or inability to use limbs, tremors, paralysis, confinement, etc.

Cognitively Disabled -- The Applicant is “Cognitively Disabled” if the Applicant is unable to read or unable to use standard printed materials, due to organic dysfunction, failure of intellectual development, or accepted mental or behavioral disability.

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