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FORM F Community Services of Northeast Texas, Inc.
711 Revised 304 E.Houston ● P.O. Box 427
FEB 16, 2018 Linden, Texas 75563
Standard Information Release Approved for all programs
Applicant Name:
Applicant File Number:
I hereby give my persmission to Community Services of Northeast Texas, Inc.
for the following, and do affirm the stated understandings:
• CSNT may obtain information to complete my application for assistance or services.
• CSNT may share necessary information with other individuals or organizations in order
to provide case management services and/or secure resources on my behalf. I understand
information will only be shared when necessary to meet the requirements of my
established service plan.
• CSNT may use my success story, likeness, recording, both audio and video in public
relations efforts, and may share same with other entities with or without personal identifying
information when doing so shall be for the good of improving community development.
• I understand CSNT may use my likeness and/or success story in releasing annual report
information to State and Federal entities, and in doing so, will provide ever assurance that
personal identifying information will be redacted.
• I understand I am not entitled to any compensation for any use of my story or likeness.
• I will continue to provide income information for Case Management reasons for as long
as necessary for CSNT to release me from the Self-Sufficiency Program.
Applicant's Signature Date
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