OCFS-1002 (Rev. 10/2013)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind
APPLICATION FOR SERVICE

Notice: This form may be submitted by a person who is blind or who has seriously impaired vision, or by an individual or agency on behalf of a blind person. Please return promptly in the preaddressed envelope provided.

 

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Full First Name, Middle Initial, Last Name
:
- - -
City: State:
Email:
Services Needed: (Check the services below that you think you need.)  




Remarks: you may use this space to give additional information on items checked above.

For applicants under the age of 21, please complete the following:

Cause of Visual Impairment:



If Yes, Describe:

Have you previously received services from this agency?:

I AM APPLYING FOR SERVICE FROM THE NEW YORK STATE COMMISSION FOR THE BLIND AND AGREE TO COOPERATE IN OBTAINING INFORMATION TO DETERMINE MY ELIGIBILITY FOR SERVICES.

DATE:
DATE:

IF APPLICANT IS SUBMITTED BY ANOTHER INDIVIDUAL OR AGENCY, FILL IN BELOW AND HAVE APPLICANT SIGN OTHER SIDE

NAME/AGENCY/ADDRESS:

PURSUANT TO THE PROVISIONS OF TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, AND THE REHABILITATION ACT OF 1973 AS AMENDED, AND THE REGULATIONS ISSUED THEREUNDER, THE SERVICES OF THE NEW YORK STATE COMMISSION FOR THE BLIND ARE CONDUCTED IN SUCH A MANNER THAT NO PERSON WILL BE EXCLUDED FROM PARTICIPATION, BE DENIED THE BENEFITS OF, OR BE SUBJECTED TO DISCRIMINATION UNDER SUCH PROGRAM ON THE GROUNDS OF SEX, RACE, AGE, CREED, COLOR, NATIONAL ORIGIN, OR HANDICAP; AND THE STATE AGENCY IS IN FACT ADMINISTERING THE PROGRAM IN ACCORDANCE WITH THE LAW AND THE REGULATIONS.

PURSUANT TO SECTION 504 OF THE REHABILITATION ACT OF 1973, AS AMENDED, NO OTHERWISE QUALIFIED HANDICAPPED INDIVIDUAL IN THE UNITED STATES SHALL, SOLEY BY REASON OF HIS HANDICAP, BE EXCLUDED FROM THE PARTICIPATION IN, BE DENIED THE BENEFITS OF OR BE SUBJECTED TO DISCRIMINATION UNDER ANY PROGRAM OR ACTIVITY RECEIVING FEDERAL FINANCIAL ASSISTANCE.