Life-Skills, Inc. > Apply for Ticket to Work Ticket to Work Registration Name * Street Address * City/Town * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 No Recent Work History (if any) Employer Start Date End Date Wage Per Hour Hours Per Week reCAPTCHA Δ