VULNERABLE CONSUMER REGISTER

APPLICATION FORM

VULNERABLE CONSUMER REGISTER

For full details on the 111 Vulnerable Consumer Register visit us at:
https://www.planb.co.nz/solutions/vulnerable-consumer-register

*Note: The Code only applies to landline voice services. Broadband only customers cannot apply.

1. Are you the account holder or listed as an authority on the account?

Yes (Fill out 3a)

No (Go to Q2)

2. Are you a person listed as an authority on the customer’s account?

Yes (Fill out 3a & 3b)

No *You must be added as an authority to the customer’s account before you make this application

3a. Details of customer

What is the account number for this service?

What is the address receiving phone service?

3b. Details of person as an authority on the customer’s account *Please only fill out this section if you are not the customer.

4. What is the preferred method of contact? (Please tick)

Home Phone

Mobile

Email

Mail

5. Are you making this application for yourself, or on behalf of someone else?

Myself

On behalf of someone else

5a. Details of person who wants to be covered by the 111 contact code *Please only fill out this section if you are applying on behalf of someone else.

6. Please select which category most closely relates to the specific circumstance of the person who wants to be covered by the 111 Contact Code?

Health

Safety

Disability

7. Is the specific circumstance of the person permanent or temporary?

Permanent

Temporary *If you selected ‘Temporary’, what is the estimated period of time the category of particular risk will apply to the person (weeks, months, years)?

8. What information is being provided in support of the application?

Sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (Fill in 8a).

Details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (Fill in 8b and 8c).

8a. Sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service *Please attach this supporting evidence to your application.

8b. Details of Nominated Person

8c. Declaration regarding nominated person *Please note that if you are making this application on behalf of someone else, before completing this declaration, you must have received permission from that person to authorise us to contact the nominated person

I authorise PLAN.B to contact

for the purposes of verifying that I (or the person I am applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.

Signature

Clear

General Declaration

I acknowledge and declare that I have read the contents of the information guide attached to this application form;

I understand that PLAN.B cannot guarantee continuous or fault free service.

I am aware of the limitations of calling 111 in the event of a power outage, and I am aware that some new telecommunications technologies and devices will not work in a power failure (such as fibre, cordless phones and medical alarms with no inbuilt battery).

I understand that PLAN.B will not always be able to inform me in advance if services will be unavailable.

I acknowledge and declare that, to the best of my knowledge, the information given in the application form is true and correct.

I acknowledge and declare that

• is (or will become) at particular risk of requiring the 111 emergency service

• Does not have a means to contact the 111 emergency service at the premises that can be operated for a continuous 8-hour period in the event of a power failure.

I understand that the information I have provided in this form will be stored with Plan B Limited.

I understand that the information I have provided in this form may be shared with relevant third parties for the purposes of providing and managing my service.

Signature

Clear

*By signing or ticking these boxes I confirm that I have read and agree to the PLAN.B Declaration.