001 Application/Referral Form



PRIVATE DIVISION OF BLIND SERVICESPRIVATE REFERRAL AND APPLICATION FOR SERVICESUpdated and revised 10/09 DBS Use: VR - IL - CP__ FORMTEXT ?????_________________ Date Received: (Date Stamp)Last Name FORMTEXT ?????First FORMTEXT ?????MI FORMTEXT ?Social Security Number FORMTEXT ?????Florida Department of Education Division of Blind ServicesSocial Security Number Collection PolicyIn compliance with Section 119.071(5), Florida Statutes, this statement serves to notify you of the purpose for the collection and usage of your social security number by the Florida Department of Education, Division of Blind Services (“Division”).?Collection of social security numbers is imperative for the performance of the Division’s duty to maximize employment opportunities for individuals who are blind; to aid such individuals in finding employment; and to increase their independence and self-sufficiency. Date of Birth FORMTEXT ?????Home Phone # FORMTEXT ?????Cell Phone # FORMTEXT ?????Other Phone # FORMTEXT ?????Street Address or PO Box FORMTEXT ?????If applicable list apartment # and name or Lot number and name of park FORMTEXT ?????Directions to your home FORMTEXT ?????Email address FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????Zip FORMTEXT ?????Race FORMTEXT ?????Registered Voter Yes FORMTEXT ?No FORMTEXT ?Primary Language FORMTEXT ?????Sex FORMTEXT ?????Marital Status FORMTEXT ?????Highest Level of Education FORMTEXT ?????Last school attended and date FORMTEXT ?????Are you a Veteran Yes FORMTEXT ?No FORMTEXT ?Referred by FORMTEXT ?????Emergency Contact not living with you (Name, Address, & Relationship) FORMTEXT ?????US Citizen Yes FORMTEXT ?No FORMTEXT ?(If no list status) FORMTEXT ?????Are you employed? FORMTEXT ?????If yes, full-time or part-time FORMTEXT ?????If yes, what is your position title? FORMTEXT ?????Eye Condition FORMTEXT ?????Eye Physician FORMTEXT ?????Date Last Seen FORMTEXT ?????Have you ever received services from this Agency? FORMTEXT ?Yes FORMTEXT ?NoIf yes, when? FORMTEXT ?????I understand that I am applying for services from the Division of Blind Services and that all eligibility is determined without regard to race, color, religion, sex, national origin, age marital status, or handicap.SignatureDate FORMTEXT ?????Parent or Guardian SignatureDate FORMTEXT ?????I would like information in: FORMTEXT ?regular print FORMTEXT ?large print FORMTEXT ?on tape FORMTEXT ?BrailleI am interested in the following service(s): FORMTEXT ?Independent Living Training FORMTEXT ?Counseling FORMTEXT ?Job Training FORMTEXT ?Eye Medical Services FORMTEXT ?Job Placement FORMTEXT ?Talking Books FORMTEXT ?Assistance to Maintain Job FORMTEXT ?Other FORMTEXT ?????Local Blind Service Office Addresses Located on BackDIVISION OF BLIND SERVICES DISTRICT OFFICESDivision of Blind Services14 W. Jordan StreetSuite 1MPensacola, FL 32501850-595-5282Division of Blind Services(Satellite office of Pensacola) 234 Forest Park CirclePanama City, FL 32405Tel: 850/872-4181Division of Blind Services1320 Executive Center DriveAtkins Bldg. 201Tallahassee, FL 32399Tel: 850/245-0307 or 1-800-672-7038Division of Blind Services1809 Art Museum Drive, Suite 201Jacksonville, FL 32207Tel: 904/348-2730 or 1-800-226-6356 Division of Blind Services417 S.W. 8th StreetGainesville, FL 32601Tel: 352/955-2075 OR 1-800-443-0908Division of Blind Services1185 Dunn AvenueDaytona Beach, FL 32114Tel: 386/254-3800 or 1-800-329-3801Division of Blind Services400 W. Robinson Street, Suite 102Orlando, FL 32801-1784Tel: 407/245-0700Division of Blind Services415 S. Armenia AvenueTampa, FL 33609-3313Tel: 813/871-7190 or 1-800-757-7190Division of Blind Services(Satellite office of Tampa)402 S. Kentucky Avenue, Room 310Lakeland, FL 33801Tel: 863/499-2385Division of Blind Services(Satellite office of Tampa)3637 4th Street North, Suite 310St. Petersburg, FL 33704Tel: 727/893-2341 or 1-800-909-9632Division of Blind Services(Satellite office of Ft. Myers)5117 26th Street West, Suite ABradenton, FL 34207Tel: 941/751-7670 or 1-800-500-6412Division of Blind Services2830 Winkler AvenueP.O. Box 7348Ft. Myers, FL 33911-7348Tel: 239/278-7130 or 1-800-219-0180Division of Blind Services2000 Palm Beach Lakes Blvd., Suite 300West Palm Beach, FL 33401Tel: 561/681-2548 or 1-866-225-0794Division of Blind Services2200 W. Commercial Blvd., Suite 101Ft. Lauderdale, FL 33309Tel: 954/497-3360Division of Blind Services401 N.W. 2nd Avenue, Room S-712Miami, FL 33128Tel: 305/377-5339 or 1-888-529-1830 ................
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