Form 10-007 - Application For Services Form Page 3
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1
2
3Application for Services
Name:_________________________________________________________________________________________________________________
(Last
(First)
(Suffix)
(MI)
SS#: *_________________________________________
.Referrals
11.
To
Date
Contact
Address/Telephone #
I have received a copy of:
The Bill of Rights of Persons who are Developmentally Disabled, section 393.13, Florida Statutes.
Family Care Council Brochure
Serving Floridians with Developmental Disabilities - brochure
Agency for Persons with Disabilities Guide to Administrative Hearings- brochure
Right to Privacy – brochure
* The collection of social security number is for record keeping purposes and is imperative to the agency’s duties and responsibilities as prescribed
by law. The social security number collected will not be available to the general public.
Page 3
FORM TITLE: APPLICATION FOR SERVICES, RULE 65G-4.016
FORM NUMBER: 10-007
YEAR: 2007
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