Apply for Employment Services

Today's Date*

First Name*

Middle Initial

Last Name*

Address*

City*

State*

ZIP/ Postal Code*

Phone*

Email*

Date of Birth*

Date Last Worked

Are You Currently working with Utah Vocational Rehabilitation Services?*

Yes
No

Have you ever been convicted of a felony?*

Yes
No

If Yes, Please Explain:

If Yes, Please provide the date of conviction:

What services do you feel you will need as you seek to return to work? Select all that apply:*

If Other, please explain:

What are your career goals? (I.E. Job or occupation you are seeking):*

Salary Expectation?:*

Hours per Week?:

Does your disability limit or restrict the types of work you can do?:

Yes
No

Please Explain:

Please indicate the monthly amount of your SSDI:*

Please indicate the monthly amount of your SSI:*

Do you have Medicare and/or Medicad?

Medicare
Medicaid
Both

Do you have a valid drivers license?

Yes
No

If no, how will you get to work?:

What is the highest level of education you completed?:

If you have special training or a college degree, what field is it in?:

List any licenses or certifications received and if they are current:

Employment Information the space provided, please list all employment for the past 10 years starting with the last position you held. Additionally, you may send your resume if you have one. Employer 1: Employer Name:

Position/Job Title:

From:

To:

Responsabilities:

Reason for Leaving:

Employer 2: Employer Name:

Position/Job Title:

From:

To:

Responsibilities:

Reason for Leaving:

Other Information If you have ever been let go (terminated) from any position, please explain:

Briefly explain any gaps in your previous work history:

How did you hear about us?*

Vocational Rehabilitation
Phone Call
Mailer
Walk-In
Other Community Agencies
Text
Word of Mouth

Comments:

Attach Resume

Max. file size: 256 MB.