q Ting Hmong q Ch Ni Braille q Ch in ln (Ting Anh) q Ch in ln (Ting Ty Ban Nha)

Ngi Thay Th Lin Lc (Tn & H)

Quan H

S T Cm Tay ( )

a Ch

S in Thoi Bn ( ) S in Thoi Cm Tay ( )

a Ch Email

Nm Sinh (khng bt buc)

Tn Cng Ty in Thoi a Phng ca Qu V

Tn trn Ha n in Thoi (Tn & H)

n Ghi Danh v Tha Thun Cho Vay dnh cho in Thoi Chuyn Dng CTAP

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Ghi Danh Ngay Hm Nay! 3 Bc D Dng: 1. Hon thnh mc ny.

H Tn Tn m

CA Thnh Ph Tiu Bang Zip

Dn tc (khng bt buc): q Ngi da trng q Ngi La Tinh q Ngi M Gc Phi q Ngi M Bn a q Ngi Dn o Thi Bnh Dng q Ngi Chu q Ngi khc

Ti mun ti liu bng: q Ting Anh q Ting Ty Ban Nha q Ting Trung Quc q Ting Vit q Ting Nga

CH , C TRC KHI K Tha Thun v Trch Nhim Php L Hu Hn Ngi np n theo y ng rng y Ban Tin ch Cng Cng California (CPUC) v/hoc Tiu Bang California, v/hoc T Chc Truy Cp Truyn Thng California (California Communications Access Foundation - CCAF) khng bo m, theo ngha en hay ngha bng, v vic s hu, s dng, tnh trng, v/hoc hot ng ca thit b vin thng c cung cp cho ngi np n theo chng trnh ny (Thit B). Ngi np n theo y ng min trch nhim php l, bo v, v gi v hi cho CPUC, Tiu Bang California, v/hoc CCAF khi bt k v tt c cc chi ph, khiu ni bn th ba no (bao gm v khng gii hn ph lut s hp l), v cc tn tht pht sinh t hoc lin quan n vic s hu, s dng, tnh trng, v/hoc hot ng ca Thit B. Ngi np n theo y ng rng CPUC, Tiu Bang California, v/hoc CCAF s khng phi chu trch nhim php l i vi ngi np n hoc bt k ngi no khc lin quan n trch nhim php l, tn tht, hay thit hi trc tip hoc gin tip gy ra hoc b co buc l gy ra, do hoc thng qua vic s hu, s dng, v/hoc hot ng ca Thit B. Ti xc nhn rng ti sng trong h gia nh ghi danh dch v in thoi a phng ti California.LU Y: Xin chon can than thiet b cua quy v v chung toi muon cung cap mot may ien thoai thch hp nhat cho quy v. CTAP se sa cha hoac oi thiet b neu 1) thiet b cho ngi mn ngng hoat ong hoac b truc trac hoac 2) ngi s dung co chng t cho thay co thay oi ve tnh trang tan tat cua ho. Xin gi lai thiet b cua quy v vi tat ca cac bo phan nguyen thuy trong hop ng cua nha san xuat. THNG CO BO MT QUYN T NHN: C quan CPUC DDTP, chiu theo quyn hnh ca Public Utilities Code 2881 (B lut Tin ch Cng Cng), c x dng mu phiu ny thu thp thng tin c nhn ch thun ty dnh cho cc mc ch xc tin cc th tc nhn din v thit lp vn kin. Tr khi c n nh mt cch khc, tt c cc thng tin yu cu cung cp phi c coi nh l quy nh phi in , v nu cung cp khng cc thng tin i hi s a n hu qu l n s khng c x l tha ng. Cc thng tin cung cp s c gi b mt theo mc lut php cho php v s sn sng cho qu v duyt xt, nu c yu cu. C quan DDTP tun hnh theo cc o Lut Hnh X V Thng Tin ca nm 1977, v Chnh Sch Gi Quyn T Nhn v trao i thng tin c ng ti trn mng http://ddtp.cpuc.ca.gov/privacy.aspx.

Ch K Ngi Np n Ngy Ai Tiu Chun Xc Nhn Vic Ti iu Kin Nhn Thit B? Sau khi hon thnh mc 1, hy mang mu n ny ti mt trong cc i din chng nhn sau h k mu n ca qu v: Bc S Y Khoa, Ph T Bc S, Chuyn Gia Thnh Hc, Bc S Phu Thut, Ngi Cp Pht Thit B Tr Thnh, Bc S o Th Lc, Bc S ca C Quan Cu Chin Binh, C Vn Phc Hi Chc Nng Ngh Nghip ca C Quan Phc Hi Chc Nng, Gim Qun Trng dnh cho Ngi Khim Thnh ti Riverside/Fremont CA, hay Chuyn Gia v m Ng. Mt trong cc i din chng nhn ny cn in mc 2 trc khi qu v c th np ti liu cho chng ti. Chng ti khng chp nhn ch k ca Chuyn Gia Dc Tho, Chuyn Gia Nn Bp Ct Sng hay Chuyn Gia Chm Cu.

http://ddtp.cpuc.ca.gov/privacy.aspx

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2. ngh i din chng nhn c y quyn hon thnh mc ny.Have this section completed by an authorized certifying agent.

q Licensed Medical Doctor q Licensed Optometrist q Licensed Audiologistq Department of Rehabilitation Counselorq Superintendent/Audiologist from the California School for the Deaf Fremont/Riversideq Licensed Hearing Aid Dispenser (see provision below)*q Licensed Physician Assistant q Licensed Speech-Language Pathologist

Impairment(s) of the Applicant (Check All That Apply): q Deaf/Deafened q Mobility/Manipulation q Hard of Hearing q Blind q Low Vision q Speech q CognitiveHearing Loss: q Mild q Moderate q Severe Mobility: q Upper body q Lower Body q Both

Notes: ___________________________________________________________________________________________________________________

Signatory please write patients 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 individuals hearingrecords on file.

________________________________________________________________________ ( _______ ) _________________________ Signature (Hearing Aid Dispensers only) Date HAD License Number Telephone

3. Chn mt cch gi li mu ny.Mang mu n in ca qu v ti mt trong s cc Trung Tm Dch V ca chng ti vnhn in thoi trong cng ngy: Xem cc a im Trung Tm Dch V trn trang web ny(www.californiaphones.org)

CTAP/California PhonesGi th qua ng bu in n: P.O. Box 30310, Stockton, CA 95213

Gi Fax n: 1-800-889-3974

Nu qu v gi qua ng bu in hoc gi fax mu n, hy ch th ph duyt c gi qua ngbu in trong vng mt tun, v sau gi (hoc ti Trung Tm Dch V) xc nh chic in thoiph hp dnh cho mnh! Sau chng ti c th gi in thoi cho qu v hoc qu v c th n ly tiTrung Tm Dch V.

c tr gip in mu n ny, bit thm thng tin hoc cc ng dng khc, hy truy cpwww.californiaphones.org Chng ti c tr chuyn trc tuyn trn Web.

Lin h vo gi lm vic ca Trung Tm: Th Hai-Th Su (7 gi sng-6 gi chiu), Th By (9 gi sng-4 gi chiu), tr nhng ngy l.

English: 1-800-806-1191 Ting Vit: 1-855-247-0106Espaol: 1-800-949-5650 : 1-855-546-7500: 1-866-324-8747 Hmoob: 1-866-880-3394: 1-866-324-8754 TTY: 1-800-806-4474

Ch dng cho vn phng.

Processed by

Date

CRT-VN

-WEB-19I-ddtp

English email: info@CaliforniaPhones.org

Email en espaol: info-es@CaliforniaPhones.org

http:info-es@CaliforniaPhones.orghttp:info@CaliforniaPhones.orghttp:www.californiaphones.orghttp:www.californiaphones.orgLast Name: First Name: MI: Street Address: City: Zip: Email Address: Year of Birth optional: Local Phone Companys Name: Name on Phone Bill (First & Last): Caucasian: OffLatino: OffAfrican American: OffNative American: OffPacific Islander: OffAsian: OffEnglish: OffSpanish: OffChinese: OffVietnamese: OffRussian: OffHmong: OffBraille: OffLarge_Print_Englilsh: OffLarge_Print_Spanish: OffAlternate Contact First Last: Relationship: Signature of Applicant: Date: Other: OffLMD: OffDRC: OffCaSchDeaf: OffLO: OffLA: OffLHAD: OffLPA: OffLSLP: OffDeaf: OffMobility: OffHard: OffBlind: OffLowVis: OffSpeech: OffCognitive: OffMild: OffMod: OffSevere: OffUB: OffLB: OffBoth: OffNotes: Signatory please write patients name from page 1 here: Address of patient from page 1: Print Name Must be legible: Professional Credentials: License Number: CertTelephoneAreaCode: CertAgentTelephone: CertFaxAreaCode: FaxNumber: CertAgentSignature: Date_2: HearingAidDisSignature: CertSigDate: HAD License Number: HAD phone1: HAD phone2: Alt Phone Number: Home Area Code: Home phone Number: Mobile Area Code: Mobile Number: Alt Home Area Code: Alt Mobile Area Code: Alt Mobile Phone Number: