Application for Services - Florida
Application for Services Updated January 21, 2016 1 Region/Field Office: _______ Phone #: ____________________________ Name of APD Staff Person: Date of Application : ___/___/_____ 1. Applicant Information Name: ________________________________________ ____________ SS#: * _______________________________________ (Last) (First) (MI) (Suffix) Address: ________________________________________ ___________ Medicaid #: ___________________________________ ________________________________________ ___________________ Phone #: ____________________________________ Email: ________________________________________ _____________ Alternate Phone #: ____________________________ DOB: _______ Sex: ____ Race (for data purposes only): White; Black; Asian; Native American or Alaskan Native; Other Ethnicity (for data purposes only): USA; Cambodia; Cuba; Ethnic Chinese; Haiti; Laos; Mexico; Nicaragua; Poland; Puerto Rico; Russia; Vietnam; Other Hispanic Country; Other Asian Country.
Application for Services Updated January 21, 2016 3 8. Citizenship Verification (must check one) (to be filled out by APD Staff):: To receive services from APD, the applicant and parent or legal guardian (if applicable) must be domiciled in …
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