Interest Form for State Services for the Blind

We are excited you are interested in learning more about State Services for the Blind. Please fill out the form below so that we can connect you with the right staff person. If you are interested in learning more about our services for someone else, please use their name and address so the referral can go to the correct staff person.
Someone from SSB will respond to you within 3 business days.
We look forward to talking with you!

Your Name

Your address

How would you prefer to be contacted (at least one is required)?

Tennessen Warning

*Privacy Notice: This notice describes how private information about you may be used and disclosed. Please review it carefully. State Services for the Blind (SSB) is asking that you complete the form below. SSB will use this information to let you know which services may help you and to connect you with the appropriate SSB staff for further follow-up. You don’t have to give us information about yourself, but without the information we may not be able to tell you what services could help you or connect you with the right SSB staff person.
The personal information you provide on this form is private and will only be shared with staff who have a need to know the information or as required by law.

By completing and submitting this form you confirm the following:
1. You have read and understood the information provided above and you agree to supply the information requested to complete this form.

2. You understand that your information may be used as described above.