Application for Exemption from Directory Assistance Charges

Please enter the required fields below before submitting the form. If you wish to mail in the form, you may download a copy of this form to be printed and completed.

Applicant Information

(Disabled Person)

* First Name

Middle Initial

* Last Name

* City

* State

* Zip Code

* Telephone Number(s) to be Exempt
(include area code)

characters remaining

* Applicant agrees to promptly advise (or cause to be advised) Midcontinent Communications if the disability described here ceases to exist.

Agree

Person to Whom Exempt Telephone Number is Billed

(if other than Applicant)

First Name

Middle Initial

Last Name

Address

City

State

Zip

I certify that the Applicant is a full time resident member of my household. If the Applicant ceases to reside full time in my household, I will promptly advise Midcontinent Communications.

Agree

This section is to be completed ONLY by the certifying authority

The Certifying Authority must be a reputable professional whose knowledge of the specific circumstances is generally accepted and acknowledged and/or an authorized employee acting for and on behalf of a special school, institution, or other recognized entity whose knowledge under the specific circumstances is generally accepted and acknowledged.

* Name

* Title

* Phone Number

* Agency

* The applicant is:
(please check all that apply)

Blind
Visually Disabled
Physically Disabled (describe below)
Reading/Mentally Disabled (describe below)

Description

characters remaining

* I certify that the applicant has the above disability that prevents them from using a telephone directory and/or from completing telephone calls.

Agree

NOTE: The facts in this application may be reviewed periodically by Midcontinent Communications.