Free Directory Enquiry Service Application Form

Free Directory Enquiry Service Application Form Part 3 – Confirmation Thank you for your application request regarding the Free Directory Enquiry Service from BT. This free of charge service is provided for: Part 3 of this application should be completed by a qualified representative. Suitable people might be: a GP, an optician or a hospital consultant. (N.B. People who cannot use The Phone Book because an illness or disability Some representatives may charge for certifying this form). means they are unable to hold or handle it People who cannot read The Phone Book because of a visual impairment If the applicant is blind or partially sighted, please attach a or because they have dyslexia. photocopy of the “Certificate of Vision Impairment” (CVI) to this People who take their telephone service from: BT, Affiniti,AOL,BE form. This will not be returned. If a certificate is being submitted Broadband,Direct Save,NTL,One2One, Sky, Cable & Wireless UK, Colt, Easynet, Eurobell, Gamma, Invomo, OneTel, Opal, Orange, Smallworld Cable, O2, Talk Talk, then the signature section below need not be completed. Telewest, Telecom Plus, Telephonica, The Phone Co op, Thus, Tiscali, T Mobile, Tweedwind, Utilities UK, Verizon, Virgin Media, Vodafone, Wightcable and Utility Warehouse only. Signature I certify that the person named in Part 1 of this form cannot use The Phone BT Conditions for Telephone Service apply to this Service. To obtain a copy or if Book because of a permanent medical condition, permanent physical disability you have any questions about the 195 service, or the application form, please call or a sight problem our free Helpline on 0800 5870195 (open Mon – Fri. 09:00- 16.30) and a member of the Registration Team will be pleased to help you. Name of the person who can’t use The service is for the personal benefit and use of the individual registered The Phone Book. and must not be used for the benefit of third parties (i.e. it must not be used to obtain telephone numbers for anyone else or for business use). The reason the above named If this condition is abused your access to the 195 service will be revoked. BT Person cannot hold or use a may withdraw the service if it is not used or if it is not being used by a Phone Book: customer of the telephone service providers named above. Name and Address Signature of qualified representative: Name: Job title: Address (please use an official departmental Stamp otherwise the form will What to do with the form be rejected): Complete part 1 and 2; sign to accept 195 Terms & Conditions. Get a qualified representative to fill in part 3 or attach a copy of an official certificate. Please fill in every appropriate box so we process your registration quickly. Return the completed form, to the Freepost Address Below. If any part of the application form is incomplete then the application for BT’s BT 195 Registration, TH59A, Freepost (NAT12417) Sheffield S1 1AY. 195 service will be rejected. Part 1 – Details of the person that cannot use the Phone Book. Part 2 – Failure to sign below will delay your application. This section is to be completed by the person who cannot use the Phone Book, or I accept the 195 terms and conditions of service. I accept that it is my responsibility their representative. to advise BT if any of my circumstances change. If the person that cannot use the Phone Book is aged 10 to 17 then this section must be completed by a parent or guardian, on behalf of the applicant. Applicant’s signature: Surname: Pre-name: If the applicant who cannot use the Phone Book has a carer that will access the Title: Mr/Mrs/Ms/Miss or state other - service on the applicants behalf please give the carers name and ask the carer to sign below – Address: Carer’s name if applicable: Carer’s signature if applicable: Post Code: Telephone number Do you require your PIN number in Braille? (Tick for yes) from which this service will be used. Additional Information: Please include When providing directory information via the 195 service, the operator is able to area code: offer onward connection to the requested number. The onward connection call is chargeable and will display on the telephone bill. Please tick to confirm that your telephone service provider is BT or one of those mentioned above Please state which Please Note: It is not possible for calls to be charged to or connected from, all types of lines. Call discount schemes may not apply. Calls from Public Payphones can be connected on request, but the connection will BT 1471 caller return is available free of charge for BT customers only. Normal call be chargeable. charge rates will still apply. Please enter your BT account number Your PIN number for accessing the 195 Service is for your Personal use only and BT A/C number must not be used to obtain telephone numbers for anyone else or for business purposes. ______________________________________________________________ It is your responsibility to keep your PIN safe, in the event of your PIN being If the person who will be using the service is aged 10 to 17 please tick here lost or stolen then you must advise the PIN Registration team as soon as Signature of parent or guardian: practicable. Date: We consider all applications sympathetically, if your application is rejected and you disagree with our decision, we can arrange for an independent medical assessment of your condition by a doctor. Issue 16 December 2010 .

Load more