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Rehabilitation Services Agencies.

Update Listing Form.

     Use this form to update information in your agency's current listing. 
You must fill in 

1.   Your name.
2.   E-Mail address.
3.   Password (if any).
4.   Your agency's name.

Then please fill in only those items that have changed.


* 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: __________ (If you used one.)
  Agency Web Site URL: http://_________________________
* 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 up to 5 E-Mail addresses. You can also provide a 
description or person's name for each of the 5 E-Mail addresses. 

E-Mail:   Name or description - name@agency.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. 

1. Be no more than 75 words. 
2. 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 multiple 
items with a blank line. This list is not for listing articles published 
by individuals or agencies in journals, magazines, newspapers or other 
periodicals. 

1. 
2. 
3. 
4. 
5. 


Type of services provided.

                                               
Comments: 


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