SEE OTHER SIDE FOR STEP-BY-STEP INSTRUCTIONS
Print your name, date of birth, current mailing address and phone number on the designated lines. STEP 2: In this area, print the name, town, and phone number of the . agency or counselor you have chosen. STEP 3: Initial. all areas that designate information you wish to give . permission to disclose. Please do not use an “X” or a “(”. ................
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