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Get Job Placement Services Referral - Texas Department Of Assistive ...

R responses, or handwrite using blue or black ink. Answer all questions. Before faxing, emailing, or mailing to the provider, review this form to ensure all questions have been answered. Note: The DRS counselor collects the information and completes all sections of this form. A. Consumer Identification Information Consumer's name: Street address (include apartment number, if any): City: State: ZIP code: Primary contact number: Secondary contact number: Email address: Social Security.

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