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CONFIDENTIAL REFERRAL FORM Name Address City State Telephone Age Zip code Social Security DOB Highest Grade of School Completed What is your Disability Are you physically able to come to this office Yes NO Have you ever applied to DVRS before If Yes where When Do you speak English Referred by Completed forms can be accepted by any local DVRS location click link below or faxed to Central Office at 609 292-8347.

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