OCFS-2150 (Rev. 10/2013)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind

STATE REHABILITATION COUNCIL APPLICATION FORM

General Information

@ .

Affiliations

The Rehabilitation Act, as amended in 1998, mandates that the State Rehabilitative Council (SRC) have statewide representation to include a majority of members who are blind or visually impaired, and the membership include advocates, employers, and providers of services for people who are blind or visually impaired. To assist in assuring proper representation on the SRC, please check the categories that reflect your affiliations.









Organization Name/Address:

Accomodations

Attachments




By signing below, I hereby agree that all information included in this application is truthful and accurate. I assure that this form is complete and all required documents are attached.

Demographics (Optional)

Gender:

Race:

Age:

NYS Region:

Disability:

Return completed forms and all attachments to the SRC Liaison:

Mail: SRC Membership, NYS Commission for the Blind

52 Washington Street, South Building, Room 201

Rensselaer, NY 12144

FAX: 518-486-5819