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Qwest Center for Customers with Disabilities (CCD)

Application For Credit - Minnesota Specialized Customer Premise Equipment

I. Application

The “Applicant” is the person applying for credit and must be a current Qwest Corporation Customer. If the Disabled Person is not a current Qwest Corporation customer, but may enter into a binding contract, the Disabled Person and the Person Applying for Credit must complete and sign this Application and they will be “Joint Applicants”.

Disabled Person
   
Applicant - If Disabled Person is not a Qwest Customer
Relationship to Disabled Customer: Spouse
Parent/Guardian
Provider of Service
   
The CPE must be used at the address and telephone number of the Applicant:
Address:
City:
State:
Zip Code:
Area Code/Telephone Number:

The information provided on or in connection with this Application is true and correct to the best of our/my knowledge; Qwest may take such action to review, verify, or confirm any such information as well as relevant credit information; the Applicant(s) is/are full-time resident(s) at the above address and/or the disabled person is a full-time resident member of the household of the Applicant at the above address; if the Application is granted and the loan advanced, the Applicant(s) agrees to repay the full amount advanced, and the Applicants represent that they have read, understand and will agree to the terms, conditions and matters on the Consumer Agreement, a copy of which is attached hereto and incorporated herein; and if the disability described herein ceases to exist, the Applicant(s) will promptly advise Qwest.
Signature of Applicant:
Printed Applicant Name:
Signature of Applicant Name, If Other Than Disabled Person:
Printed Applicant Name If Other Than Disabled Person:
 

II. Certification

THIS SECTION TO BE COMPLETED ONLY BY THE CERTIFYING AUTHORITY

Qualified Certifying Authorities include those identified in 36 C.F.R. Section 701.10(b)(2): Doctors of medicine, osteopathy, and ophthalmology; registered nurses, therapists, and professional staff of hospitals, institutions and public or welfare agencies; and (where competent) professional librarians or others 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.
Legally blind
Visually Disabled
Physicaly Disabled
Hearing Impaired
Description:  
Signature of Certifying Authority:
Printed Name of Certifying Authority:
Title and Agency, if applicable:
Printed Name of Title and Agency:
Date:
The facts in this Application and Certification may be reviewed and confirmed periodically be Qwest Corporation

III. Loan Amount/Purchase Information

Purchase Price without taxes::
Price without taxes:
 
If computer equipment and software/modem:
Product Vendor, Name and Number:
Product Description:
Price without taxes:
Product Vendor, Name and Number:
Product Description:
Price without taxes:
   
Amount/Total Price w/out taxes:
Note: Qwest does not fund taxes.
   
If computer equipment and software/modem are to be purchased:
Who in the household will be using the computer and software/modem?
What is the computer and software/modem going to be used for?
   
The Applicant(s) certify that all products listed hereon will be used for telecommunications purposes.
   
Select number of months you wish to pay on credit agreement:
3    6    9    12    15    18    24    30    36    42    48    54    60
Note: Total loan amount must be repaid in equal monthly payments over not more than 60 months and each payment amount must be no less that five dollars ($5.00).

IV. Vendor Information
[Note, if buying equipment from Qwest , do not complete this Section]

Vendor 1 Name:
Vendor 1 Street Address:
Vendor 1 City:
Vendor 1 State:
Vendor 1 Zip Code:
Employer Identification Number:
Tax Identification Number:
   
Vendor 2 Name:
Vendor 2 Street Address:
Vendor 2 City:
Vendor 2 State:
Vendor 2 Zip Code:
Employer Identification Number:
Tax Identification Number:
   

Remember to supply the information for each Computer Vendor and for each software/modem Vendor separately.

Note to Vendor: Equipment price must exceed $50.00 and be less than $1600.00.
For Company Use Only: Do not write below this line
 

Return Completed Application to:

Application for Discount for Minnesota Customers on Speed Dial 8 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):

To be completed if the telephone number to be exempted is in the name of someone 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.

  • Last Name:
    • First Name: Middle Initial: Signature of person to whom service is billed: Telephone Number:

SECTION BELOW TO BE COMPLETED ONLY BY THE CERTIFYING AUTHORITY

Qualified Certifying Authorities Include:

Minnesota (MN) ONLY:

  • * Licensed Doctor/Nurse, Ophthalmologist or Optometrist
  • * Professional Hospital Staff Member
  • * Therapist
  • * Institutions and public welfare agencies
  • * Professional librarian or any person acceptable to the
  • U.S. Librarian of Congress as having the competence in identifying physical disability that is sufficiently severe to prevent reading or using conventional reading materials.

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:
  • Title and Agency:
  • Date:

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

  • For Company Use Only
  • Order Number
  • Issued By
  • DD

Definitions of Visual, Physical and Mental Disabilities
(Based on 36 C.F.R. 701.10)

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

Blind --- The applicant is “Blind” if the Applicant’s visual acuity is 20/200 or less in the better eye, with correcting glasses, or if the Applicant’s widest diameter where visual field subtends angular distance no greater than 20 degrees.

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.

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

Reading/Mentally Disabled --- The Applicant is “Reading/Mentally 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:

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
 
This application qualifies for a Credit Agreement for Disabled Persons.
Approved By: Manager CCD
Date:
 
Consumer Agreement Follows