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We provide telecommunications access for Californians with
hearing, vision, cognitive, mobility, and speech-related disabilities.

Need help filling out your application?
Give us a call at 1-800-806-1191

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Company

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First Name*

Middle Initial

Last Name*

Street Address*

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Address Line 2

City*

State*

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Zip Code*

Email*

Phone number/VP*

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Phone Type*

Disability Type*

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Marketing Opt-In Consent

By checking this box, I consent to receiving marketing materials about California Connect’s equipment and services. I understand that I can opt out at any time by emailing info@caconnect.org or calling 1-800-806-1191.

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.

Signature of Applicant*

Date of Signature*

If you are not currently with a Medical Professional who can provide their signature, please select "No" to the question below and then click the "Next" button to continue your application.

Are you a Medical Professional?*

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To be completed by a Medical Professional

First Name*

Last Name*

Occupation*

Medical License Number

Business Address*

Business Address 2

City*

State*

Zip Code*

Business Email Address*

Business Phone Number*

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Optional

Drop files here or

Accepted file types: pdf, doc, docx, png, jpg, jpeg, gif, bmp, Max. file size: 3 MB.

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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.

Signature of Professional*

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Date of Signature*

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Professional Consent and Signature