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Application For Assitance If you would like to apply for assistance, please complete and "Send" this form to HDRC. Last Name: First Name: Street Address: City: State: Zip Code: Phone: Email Address: Age: Birthdate: (MM/DD/YYYY) Disability: Briefly Describe Your Problem: Who is representing you or assisting you with your problem? If you are having difficulty using this form: You may request this form over the telephone. Please call: 1-800-882-1057 Or send us the information requested above by email: HelpMe@HawaiiDisabilityRights.org