Fillable Online Cert Form English.PDF (California)

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Online Cert Form English.PDF (California)

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The Online Cert Form English.PDF (California) form is 2 pages long and contains:

  • 0 signatures
  • 38 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

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IMPORTANT, READ BEFORE SIGNING Limited Liability Agreement The applicant hereby agrees that the CPUC and/or the State of
California, and/or the California Communications Access Foundation (CCAF) make(s) no warranties, either express or implied, with
regard to the possession, use, condition, and/or operation of the telecommunications equipment provided to applicant as part of this
program (the Equipment). The applicant hereby agrees to indemnify, defend, and hold harmless the CPUC, the State of California,
and/or the CCAF from any and all third party claims, costs (including without limitation reasonable attorneys’ fees), and losses
which in any way arise out of or in connection with the possession, use, condition, and/or operation of the Equipment. The applicant
hereby agrees that the CPUC, the State of California, and/or the CCAF shall have no liability to the applicant or any other person with
respect to any liability, loss, or damage caused or alleged to be caused, directly or indirectly, by or through the possession, use, and/or
operation of the Equipment. I verify that I live in a household that subscribes to telephone service in California.
NOTE: Please choose your equipment carefully because we want to provide you the most appropriate phone. CTAP will repair or
exchange equipment if 1) the equipment loaned to the consumer stops working or malfunctions or 2) the consumer’s disability
certification changes. Please return your equipment with all original parts in the manufacturer’s packaging.
PRIVACY NOTICE: The CPUC DDTP, under the authority of Public Utilities Code § 2881, uses this form to collect personal information
solely for the purposes of identification and document processing. Unless otherwise noted, all requested information is mandatory, and
incomplete information may result in incorrect processing. The information submitted will be held in confidence to the extent allowed by
law and is available for your review, upon request. The DDTP complies with the Information Practices Act of 1977, and its Privacy Policy
and contact information are online at http://ddtp.cpuc.ca.gov/privacy.aspx.
Apply Today! 3 Easy Steps:
1. Complete this section.
First Name MI
City Zip
Year of Birth (optional)
Last Name
Street Address
Home Phone Number
Email Address
Local
Phone Company’s Name
Name on Phone Bill (First & Last)
Ethnicity (optional):
Native American Pacific Islander Asian Other
I prefer materials in: English Spanish Chinese Vietnamese
Russian Hmong Braille Large Print (English)
Large Print (Spanish)
Alternate Contact (First & Last)
Relationship
Phone Number
Date
Page 1 of 2
Application and Loan Agreement for CTAP Specialized Phones
Signature of Applicant
State
Mobile Phone Number
Caucasian Latino African American
(  )
(  )
(  )
California Telephone Access Program
Print now and ask your authorized certifying professional to complete section two and return the
form to you to sign and submit.
CA
2. Have this section completed by an authorized
Page 2 of 2
certifying agent.
Licensed Medical Doctor (MD) Licensed Physician Assistant Licensed Nurse Practitioner
Department of Rehabilitation Counselor Licensed Optometrist
Licensed Audiologist Licensed Speech-Language Pathologist
Superintendent/Audiologist from the California School for the Deaf Fremont/Riverside
Licensed Hearing Aid Dispenser (see provision below)*
Impairment(s) of the Applicant (Check All That Apply):
Deaf/Deafened Mobility/Manipulation Hard of Hearing Blind Low Vision Speech Cognitive
Hearing Loss: Mild Moderate Severe Mobility: Upper body Lower Body Both
Notes: ___________________________________________________________________________________
Signatory please write patient’s name from page 1 here: ___________________________________________
Address of patient from page 1: ______________________________________________________________
_
I certify that the above named person has the impairment(s) marked above that restrict(s) his or her use of
the telephone and qualifies for equipment provided under California state legislation.
Print Name (Must be legible) __________________________________________________________________
Professional Credentials _______________________________ License Number _________________________
Telephone ( _________)________________________ Fax ( _________)_______________________________
Signature of Certifying Agent _________________________________________ Date ___________________
(No stamped signatures accepted)
*For Licensed Hearing Aid Dispensers – I certify that I have fitted the above person with an amplified device
and have the individual’s hearing records on file.
_____________________________________________________________________ (_______)_____________________
Signature (Hearing Aid Dispensers only) Date HAD License Number Telephone
Oce Use Only
Processed by Date
CRT-ENG-WEB-21J
3. Choose one way to return this form.
V
V
Bring in your completed form to one of our Service Centers and get the phone the same day:
See Service Center locations on this Web Site www.californiaphones.org/locations
Mail to: CTAP/California Phones
P.O. Box 30310, Stockton, CA 95213
V
Fax to: 1-800-889-3974
If you mail, fax, or email your completed form, you will receive a letter or phone call about how
to select the best phone for your needs and it will be shipped to you. If you bring your form to
a Service Center, you will be able to try out the phone and take it home with you.
For help completing this application, further information, or more applications, visit
www.californiaphones.org Web Chat available.
Contact Center hours: Monday–Friday (8 AM–6 PM), except holidays. Please check the website
or call the Contact Center to confirm hours.
English/ASL: 1-800-806-1191
粵語: 1-866-324-8754
Hmoob: 1-866-880-3394
國語: 1-866-324-8747
Русский: 1-855-546-7500
English email:
info@CaliforniaPhones.org
Español: 1-800-949-5650
Tiếng Việt: 1-855-247-0106
Fax: 1-800-889-3974
TTY English: 1-800-806-4474
TTY Español: 1-844-867-1135
Email en Español:
info-es@CaliforniaPhones.org
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Online Cert Form English.PDF (California)

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Completed 6 October 2021

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