Form DR108 "Authorized Representative" - California

What Is Form DR108?

This is a legal form that was released by the California Department of Rehabilitation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the California Department of Rehabilitation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DR108 by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR108 "Authorized Representative" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
AUTHORIZED REPRESENTATIVE
DR 108 (Rev. 08/12)
Please print or type.
Consumer Name
Mailing Address
Email Address
City
State
Zip Code
I request that the individual named below act on my behalf in the mediation and/or fair
hearing process.
I authorize the Department of Rehabilitation to release information related to the
mediation and/or fair hearing process to this authorized representative.
Consumer Signature
Date Signed
Print or type the information on the individual you want to act on your behalf.
Authorized Representative's Name
Mailing Address
City
State
Zip Code
Area Code and Phone Number
Email Address
Mail to:
Mediation/Fair Hearing Office
c/o Department of Rehabilitation
Legal Affairs
P. O. Box 944222
Sacramento, CA 94244-2220
Or fax to:
(916) 558-5861
Or email to:
Appealsinfo@dor.ca.gov
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
AUTHORIZED REPRESENTATIVE
DR 108 (Rev. 08/12)
Please print or type.
Consumer Name
Mailing Address
Email Address
City
State
Zip Code
I request that the individual named below act on my behalf in the mediation and/or fair
hearing process.
I authorize the Department of Rehabilitation to release information related to the
mediation and/or fair hearing process to this authorized representative.
Consumer Signature
Date Signed
Print or type the information on the individual you want to act on your behalf.
Authorized Representative's Name
Mailing Address
City
State
Zip Code
Area Code and Phone Number
Email Address
Mail to:
Mediation/Fair Hearing Office
c/o Department of Rehabilitation
Legal Affairs
P. O. Box 944222
Sacramento, CA 94244-2220
Or fax to:
(916) 558-5861
Or email to:
Appealsinfo@dor.ca.gov