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Referral for Services

Form

To refer someone to the Department for services, complete the following form. You may complete and submit the form online. If you prefer, you may print this form and mail or fax  the completed form to the address listed at the bottom of the form. (To print the form, use your browser's Print command.)

Required Information

The Department needs the following information in order to contact the individual being referred to the Department for services.

First Name:

Last Name:

Street Address:

City:        State:       Zip Code:

Phone Number, including area code:

E-mail Address: 

Birth date:

Comments:

   

Questions?

If you have a question about this referral form, you can call Curtis Chong.

    Curtis Chong's phone number: 515-281-1361 or 1-800-362-2587
    Curtis Chong's e-mail address: info@blind.state.ia.us

Mailing Address and Fax Number

Iowa Department for the Blind
524 Fourth Street
Des Moines, IA  50309
Fax Number: 515-242-5781

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