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Form Nyspl - Application For Special Services For People With Disabilities - Verizon

NEW YORK

Application for Special Services for People with Disabilities

If you have a disability that prevents you from using a rotary or touchtone telephone, or a

telephone directory, Verizon can help. To qualify for these services you must have a visual or

motion disability.

For certification of your disability, please have a Physician or Authorized Agency* complete

the second page of this application and attach a copy of your certification to this form.

*For information on Authorized Agencies, call toll free: 1-800-974-6006 (Voice & TTY)

TELEPHONE NUMBER TO BE EXEMPT

Billing Telephone Number (including area code): (________)_________________________

NAME & ADDRESS OF THE PERSON APPLYING FOR THE EXEMPTION

Name: _____________________________________________________________________

Street Address: _____________________________________________________________

City: ______________________________ State: __________

Zip Code: _____________

PLEASE CHECK ALL SERVICES REQUIRED:

 Exemption from Directory Assistance Charges (applies when your phone is used to call

411)

 Exemption from Operator Assisted Calls (applies when operator places a call for you

from your phone

 Verizon Braille Bill (provided monthly)

 Verizon Large-Print Bill (provided monthly)

Signature ________________________________________________

Date ________________

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Form NYSPL 11/18/13

Form Nyspl - Application For Special Services For People With Disabilities - Verizon