Qwest | Residential | CCD | SpeedCall 8 Form

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)

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:

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


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