形狀測試 | California Connect

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Applicant Consent

I certify under penalty of perjury that I meet the eligibility requirements including having a disability and that I am a current resident of the State of California.

I have read and fully understand the terms of this limited liability agreement and CPUC Privacy Policy. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional waiver, privacy consent and release of all liability, to the greatest extent allowed by law.

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First Name*

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Medical License Number

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Professional Consent and Signature

Professional Consent

I certify that the above-named person in the application meets the requirements of having a disability, which limits or prohibits the use of the telecommunication connectivity services, and cannot communicate without specialized equipment. I also certify that use of equipment and services for their disability could benefit this person.

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Professional Consent and Signature