Application
Form
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Instructions: Please Read or
Print before Opening.
Due to the wide range of Computers, Operating Systems,
Software Versions and your computer Skills, if you encounter problems or difficulty with the
on-line completion and printing of:
Option A. On-Line Application Form
After completion of the form on-line, you should Print It, Sign
It,
and then Fax It (985) 345-1157 or Mail it to the below
Address.
If you have problems,
Please use Option B.
Option B. Printable Application Form
Print Blank Form and Complete, Sign It, and then Fax It
to (985) 345-1157 or Mail it to the below
Address.
Both Options use Adobe PDF technolgy to ensure accurate formatting and information of Forms. To
ensure best results, you should be using latest version of Adobe Reader which can be downloaded and
installed from this Link: Adobe Reader 9
If you are unable to print Form, Please Contact
Us.
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Option A. Fill out On-Line, Print Form, Sign,
and Fax, Email,
or Mail back to Contact information below.
On-Line Application Form
Option B. Print Form, Complete,
Sign and Fax, Email,
or Mail back to Contact informtion below.
Printable Application Form
| Contact Telephone: |
(985) 345-1119
(985) 345-1157 Fax
|
| Address: |
1302 J.W. Davis Drive
Hammond, LA 70403
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E-Mail:
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Louisiana Rural Health Services Corporation