Apply for Ticket to Work | Life-Skills inc

Life-Skills, Inc. > Apply for Ticket to Work

Ticket to Work Registration

If you are human, leave this field blank.

Name *

Street Address *

City/Town *

State *

Zip Code *

Email Address *

Phone Number *

Are you between the ages of 16 and 64 and currently receiving:

Social Security Disability Benefits?

Supplemental Security Income?

Vocational Goal: *

Desired short term goal (3-12 months)

Short term monthly earnings goal (3-12 months)

Long term vocational goal (3-5years)

Long term monthly earning goal (3-5 years)

Please fill in desired job title: *

Please fill in amount of money you want to be earning per month: *

What Employment Services are you looking for? *

(ex…. skills assessment, job search assistance, resume and cover letter writing, interviewing skills, etc)

Have you ever worked with an Employment Network or State Vocational Rehabilitation Agency? *

Yes

Employer

Start Date

End Date

Wage Per Hour

Hours Per Week