Application Form

Click either of two buttons below to apply!

1) You can download the form to complete offline, then return by email or mail.  Or, click the second button to complete and return the form online.

2) For all electronic submissions, be sure to include all supporting documentation.

3) Email forms and documentation to TDTampaBayEligibility@uzurv.com

4) If you choose mail, send the for and supporting documentation to UZURV Eligibility Specialist, 413 Stuart Circle, Suite 100, Richmond, VA 23220