Apply for Employment Services

Thank you for your interest in Ability 1st Utah Employment Services and the Ticket to Work program. Please take note that the Ticket to work program is only available to persons receiving SSI or SSDI. As part of our efforts to evaluate your potential to benefit from our employment services and the possibility of participation in our employment program, please complete the questionnaire on this page. Please make every effort to fully and clearly answer all of the questions on the form.

If you require any assistance you may contact Janine at (801)-850-5560. Once we receive your application it will be reviewed, then we will follow-up and contact you.

Fields marked with * are required.

First Name*

Last Name*

Middle Initial


Address Line 2


State / Province / Region*

Postal / Zip Code*




Date of Birth*

Date Last Worked

Are You Currently working with Utah Vocational Rehabilitation Services?*


Have you ever been convicted of a felony?*


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?:

Note: Hold down CTRL on a PC and command on a mac to select multiple options.

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?:


Please Explain:

Please indicate the monthly amount of your Social Security Benefit:


What other sources of income do you receive?

Long Term Disability: Workers Comp: Other:

Do you have a valid drivers license?*


Do you have a working vehicle?:


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:




Reason for Leaving:

Employer 2: Employer Name:

Position/Job Title:




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?