APPLICATION FOR VOCATIONAL AND EMPLOYMENT SERVICES

APPLICATION FOR VOCATIONAL AND EMPLOYMENT SERVICES

Michigan Department of Labor and Economic Opportunity Michigan Rehabilitation Services
For MRS office use only Date Application received

MonthDayYear
Date
Personal Information
Name

First NameMiddle NameLast Name
Name you want to be called:
Former Last Name (if applicable):
Social Security Number:
Birth Date

MonthDayYear
Date
Gender:
Mailing Address
City
State
Zip Code
County
Email Address
Primary Phone

Area CodePhone Number
What type of phone
Secondary Phone

Area CodePhone Number
What type of phone
What is your race/ethnicity (check all that apply)
Do you consider yourself to be multi-racial?
Are you a veteran?
Were you a customer of MRS in the past?
"if so" When?
"if so" What Office?
Have you received Pre-Employment Transition Services (Pre-ETS) from MRS in the past?
"if so" When?
"if so" What Office?
Your Needs
What language do you use most of the time?

Other Explain
What language do you use for printed documents?

Other Explain
Do you need an interpreter, large print or other type of help to work with MRS?

Other Explain
Characteristics

Do you have a:

Copy of guardianship documents is required. Type of Permit
Customer Name
Marital status
Are you a registered voter?
Would you like to register to vote?
Are you a citizen of the U.S.?
If no, do you have a work Visa?
Please bring work Visa to your first appointment
Disability Information
What is your physical or mental disability? (Examples: Depression, anxiety,

substance abuse, learning disability, ADD, ADHD, cerebral palsy, arthritis, etc)
Primary or Main
Secondary or Other Disability
Does your disability affect your ability to

Other – Explain
Basic Information
What is your current living arrangement?

Other
What is your current medical coverage? (Please check all that apply)
"if selected" Private insurance through own employment - Provider
"if selected" Private insurance from other means -Provider
"if selected" Public insurance from another source. -Name of Insurance Company
Are you currently enrolled in school?
If yes, what is your expected graduation date?

MonthDayYear
Date
How did you hear about MRS (referred by)?
Income
What is your primary source of income?
"if selected" Public Support (SSI, SSDI, TANF, etc) Explain:
Customer Name

Do you receive:

Rows	Yes	No	Monthly Amount
Social Security Disability Insurance (SSID)
Supplemental Security Income (SSI)
Family Independence Program (FIP) also known as Temporary Assistance to Needy Families (TANF)
If yes, will you run out of TANF within 2 years?
State Disability Assistance (SDA) also known as General Assistance (GA) in some areas
Unemployment Insurance Benefits
Veterans Disability (VA)
Worker's Compensation
Other types of Public Assistance (Examples: government payments for retirement or survivor benefits, Aid for Dependent Children, etc.)
Other Disability Income
Long Term Disability
Auto No-Fault
Non-Cash Income - Food Assistance (also known as Bridge Card)

I understand that:
- The purpose of receiving vocational rehabilitation services is to help me get or keep a job.
- I must be found eligible for the services that I require.
- The Social Security Administration may give MRS all information necessary to determine my eligibility and verify my identity.
- MRS may contact me during or after my case has been closed to provide an opportunity to share my experience about the program.
Signature of Applicant
Date

MonthDayYear
Date
Signature of Parent or Legal Guardian, if applicable
Date

MonthDayYear
Date
The application has been reviewed and their rights and responsibilities have been discussed.
Signature (MRS Counselor)
Date

MonthDayYear
Date
Should be Empty: