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:*

MaleFemaleNon-binary or Another GenderPrefer not to answer
Mailing Address*
City*
State*
Zip Code*
County*
Email Address*
Primary Phone*

Area CodePhone Number
What type of phone*

VoiceTTYFaxCellVideo Phone
Secondary Phone

Area CodePhone Number
What type of phone

VoiceTTYFaxCellVideo Phone
What is your race/ethnicity (check all that apply)*

WhiteBlack or African AmericanHispanic or LatinoArabAsianHmongAmerican Indian or Alaskan NativeNative Hawaiian or Other Pacific Islander
Do you consider yourself to be multi-racial?*

YesNo
Are you a veteran?*

YesNo
Were you a customer of MRS in the past?*

YesNo
"if so" When?
"if so" What Office?
Have you received Pre-Employment Transition Services (Pre-ETS) from MRS in the past?*

YesNo
"if so" When?
"if so" What Office?
Your Needs
What language do you use most of the time?*

EnglishSpanishArabicAmerican Sign LanguageOther Explain
What language do you use for printed documents?*

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

YesNoOther Explain
Characteristics

Do you have a:*

	Yes	No
Legal Guardian
Michigan Driver's License
State of Michigan ID
Work Permit

Copy of guardianship documents is required. Type of Permit
Customer Name*
Marital status*

Single/Never MarriedMarriedDivorcedSeparatedWidowed
Are you a registered voter?*

YesNo
Would you like to register to vote?*

YesNo
Are you a citizen of the U.S.?*

YesNo
If no, do you have a work Visa?

YesNo
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

StandWalkSitLiftBendSeeHearReadWriteUse Hands or FeetConcentrateRememberLearnUnderstandHandle StressCommunicateControl EmotionsWork with OthersOther – Explain
Basic Information
What is your current living arrangement?*

Adult/Youth correctional facilityPrivate residence (applicant only, with family or with another person)Community residential/Group homeHalfway houseRehabilitation FacilityHomeless/shelterSubstance abuse treatment centerMental health facilityNursing homeOther
What is your current medical coverage? (Please check all that apply)*

MedicaidMedicareAffordable Care ActNonePrivate insurance through own employmentPrivate Insurance from other means. (Example: insurance is provided by a parent or a spouse.Public Insurance from another sourceNot yet eligible for private insurance through current employer
"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?*

YesNo
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?*

Personal income employment earnings, interest dividends, rent, retirement including SocialPublic Support (SSI, SSDI, TANF, etc)Family and FriendsPrivate Relief AgencyPublic Institution - Tax SupportedWorker's CompensationAll other sources (e.g., private disability insurance and private charities)
"if selected" Public Support (SSI, SSDI, TANF, etc) Explain:
Customer Name*

Do you receive:*

	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*

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Date*

MonthDayYear
Date
Signature of Parent or Legal Guardian, if applicable

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Date

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

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Date

MonthDayYear
Date
Should be Empty:

APPLICATION FOR VOCATIONAL AND EMPLOYMENT SERVICES

Personal Information

Disability Information

Basic Information

Income