RG 29-0115 (10-06)
Application for Qwest’s Specialized CPE Lease or Purchase Program Minnesota Customers Only
Applicant (Disabled Person)
Last Name Address City State Zip Code First Name MI
Person to Whom Telephone Number is Billed, if other than Applicant
Last Name First Name MI
Telephone Number(s) (include area code) I certify that the Applicant is a fulltime resident member of my household. If the Applicant ceases to reside fulltime in my household, I will promptly advise Qwest Corporation. Signature of Person to Whom Telephone Number is Billed, if other than the Applicant: Printed Name of Person to Whom Telephone Number is Billed, if other than the Applicant
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 Name of Applicant _____________________________________________
Check One:
Lease
Purchase
Check item(s) needed & color as appropriate: Volume Control –Hearing Handset - Square earpiece and mouthpiece (Only available in Ivory) Volume Control –Hearing Handset - Round earpiece and mouthpiece TTY/TDD (Text Typewriter/Telecommunications Device for the Deaf) Adjunct Volume Control Ivory Black White
Please do not alter above items if already checked for you.
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RG 29-0115 (10-06)
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 Description: _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________ Signature of Certifying Authority __________________________________ Printed Name of Certifying Authority 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).
____________________________ Title and Agency, if applicable
__________________ Date
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.
Qwest Application for Special CPE Lease or Purchase Program Minnesota Customers Only Page 2 of 3
RG 29-0115 (10-06)
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 via one of the following methods: • Mail --Qwest Center for Customers with Disabilities Qwest Corporation P. O. Box 2670 Omaha, NE 68103 TTY --1 800 223-3131 (Voice/TTY) Fax --1 866 826-4839 402 422-5008
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FOR OFFICE USE ONLY -DO WRITE BELOW THIS LINE _______ INITIAL __________ RENEWAL
Date Received ________________________________ Date Confirmed _______________________________ Service Ord No. _______________________________ Completetion Dte. ______________________________
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