CLIPBOARD LTD — 111 CONTACT CODE APPLICATION
For a residential landline consumer at particular risk of needing 111 who has no means that works for a continuous eight hours during a power cut.

Return options: post to Clipboard Ltd, 32 Kourataki Road, Baverstock, Hamilton, New Zealand; or contact support@clipboard.co.nz / 0800 257 273 for assistance. Applications can be made in any reasonable manner, including by phone, email or large print. This is not an emergency service. In an emergency use an available means to call 111.

1. PERSON WHO NEEDS COVER
Full name:
Customer account holder name:
Customer account number (ask us if unknown):
Full address where the residential landline is supplied:
Landline number:
Contact phone/email/postal address:
Safe/preferred contact method and time:
Communication/accessibility needs:

2. PERSON APPLYING ON THEIR BEHALF (if applicable)
Full name:
Contact details:
Relationship and authority to act:

3. CIRCUMSTANCES
Category most closely related to particular risk (choose one): Health / Safety / Disability
Temporary or permanent:
If temporary, estimated end date or duration:

4. VERIFICATION (choose either A or B; you do not need both)
A. Nominated person competent by occupation to verify particular risk:
Name:
Occupation:
Contact details:
Declaration: I authorise Clipboard to contact this nominated person to verify whether the person covered is or will become at particular risk of needing the 111 emergency service.
Agreed (yes/no):
OR
B. Supporting evidence supplied (describe document only):
Examples include a health-practitioner letter, medically dependent consumer certification, protection order or documentation of impairment. Supply only information needed to verify particular risk. Contact us about handling sensitive documents; do not include unnecessary diagnoses or full records.

5. DECLARATIONS (confirm each)
[ ] The person covered is or will become at particular risk of requiring the 111 emergency service.
[ ] They do not have a means of contacting 111 at the premises that can operate for a continuous eight hours during a power failure.
[ ] The information is correct to the best of my knowledge.
[ ] I understand Clipboard will store the application and may share necessary information with relevant third parties to provide and manage the service, as explained in its Privacy Statement.
[ ] If acting for another person, I have their authority or lawful authority to act.

Name of declarant:
Signature or recorded confirmation:
Date:

IMPORTANT INFORMATION
Clipboard will notify you of acceptance or decline within ten working days of receiving a complete application. We will help identify missing information. Acceptance includes arranging an appropriate means at no cost, supplied as soon as reasonably practicable, suitable for your capabilities and premises and capable of operation for a continuous eight-hour power cut when used as instructed. We cannot deny or withdraw a residential landline because someone is or may become vulnerable.

If you reject a means supplied by Clipboard that meets section H of the Code, Clipboard may treat your application as withdrawn and need not supply a means under that application. You or someone on your behalf may reapply. Tell us why an option does not meet your needs so we can assess its suitability.

Privacy: used to assess eligibility, verify circumstances, arrange and maintain a suitable means, handle concerns and meet Code recordkeeping/reporting duties. Access is limited to those who need it; necessary details may go to a verifier or equipment/service supplier. Ask us for access/correction or collection assistance. See https://clipboard.co.nz/privacy-policy/ . Do not send a completed application through social media or a public website form.

Complaints: contact support@clipboard.co.nz or 0800 257 273. If a Code disagreement is unresolved within five working days, the account customer or Clipboard can refer it to Telecommunications Dispute Resolution: https://www.tdr.org.nz/ . The account customer can refer on behalf of another person living at the premises. You may also complain to the Commerce Commission about compliance. These routes do not imply general TDR membership.

More information: https://clipboard.co.nz/111-contact-code/
Version: 16 October 2026