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Need to apply for an accessible phone, TTY, or other specialized piece of communications equipment for your own personal use at no cost to you? The process is fast and easy, just apply online.

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Give us a call at 1-800-806-1191

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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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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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