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| Personal Information |
| Email Address: |
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| First Name: |
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| Middle Initial: |
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| Last Name: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State: |
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| Zip: |
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| Telephone: |
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| Fax: |
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| Agency/Organization: |
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| Title: |
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| Please note any accommodations needed: |
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| Please check all that apply: |
Parent/Family Member
SSI or SSDI Beneficiary
Private Provider |
DRS
CSB
DSS |
DOJ
One Stop
School/Ed
Other |
If other, please specify:
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| Please select the training dates that you will attend: |
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| SSI/SSDI & Work Incentives |
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September 23rd & 24th, 2010 - Danville
September 27th and 28th - Northern Virginia
October 21st & 22nd, 2010 - Williamsburg
November 18th & 19th, 2010 - Roanoke
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This activity is provided with funding support from Virginia's Medicaid Infrastructure Grant (CMS Grant No. 1QACMS030237/02) awarded to the Department of Medical Assistance Services by the Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services |