Update Listing Form

Rehabilitation Services Agencies

Use this form to update information about your agency's current listing. You must fill in your name, E-Mail address, password (if any), and your agency's name. Then please fill in only those items that have changed.

If your browser can not handle forms click here for a text form you can E-Mail to updaterehabagencylisting@blind.net.

Do you work for this agency?	*	Yes - I work for this agency. No - I don't work for this agency.
Contact's Name:	*
Contact's E-Mail:	*
Password:
Agency Web Site URL:
Agency Name:	*
Suite #:
Agency Street Address:
P. O. Box:
City:
State:
Zip Code:
Country:
Voice - Phone:
TDD - Phone:
TOLL FREE - Phone:
FAX - Phone:

E-Mail You can list upto 5 E-Mail addresses. You can also provide a description or person's name for each of the 5 E-Mail addresses.
	Name or description	-	name@organization.com
E-Mail 1:		-
E-Mail 2:		-
E-Mail 3:		-
E-Mail 4:		-
E-Mail 5:		-

Agency Description

Your agency description must meet the following requirements and may be edited for length and/or clarity.

Be no more than 75 words. The text area is set to show 420 characters which is about 75 words; so if the text starts scrolling you've written to much.
Should only describe the services available and avoid hyperbole. (Like the plague ... or was that cliches. :) )

Agency Publications

List the publication(s) produced by your agency; catalogues, brochures, magazines, newspapers, etc. Include the name and how often each is published. Please put one publication per line or separate items with a blank line. This list is not intended for listing articles published by individuals or agencies in journals, magazines, newspapers or other periodicals.

Type of services provided

Comments

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