Application Form

Please be sure you can print from this device before completing the form.

  1. Fill out the form below.
  2. Print it
  3. Sign and have your doctor or certified professional sign
  4. Submit the printed form by mail, email, fax, or in person.

This online form cannot be saved.
No personal data is being collected or transmitted on this website.

California Connect California Telephone Access Program
California Public Utilities Commission Deaf and Disabled Telecommunications Program

Apply Today! 3 Easy Steps

1. Complete this section.


Ethnicity:
I prefer materials in:*

IMPORTANT, READ BEFORE SIGNING Limited Liability Agreement, the applicant hereby agrees that the CPUC and/or the State of California 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 and/or the State of California 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 and/or the State of California 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.

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 https://caconnect.org/privacy.

Print your application now and ask your authorized certifying professional to complete section two
and return the form to you to sign and submit.

2. Have this section completed by an authorized certifying agent.

Impairment(s) of the Applicant (Check All That Apply):
Hearing Loss:
Mobility:
Notes:
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.
Telephone ( )
Fax ( )
(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.

3. Choose one way to return this form.

Bring in your completed form to one of our Service Centers and get the phone the same day.
See Service Center location page

Mail to:

CTAP/California Connect
P.O. Box 30310, Stockton, CA 95213

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.

Contact Center hours: Monday - Friday (8:00 AM - 6:00 PM), except holidays. Please check the website or call the Contact Center at 1-800-806-1191 to confirm hours.

All Languages:
1-800-806-1191

Fax:
1-800-889-3974

TTY English:
1-800-806-4474

TTY Español:
1-844-867-1135