Maine.gov
MAINE DEPARTMENT OF LABORDIVISION OF VOCATIONAL REHABILITATION APPLICATION FOR VOCATIONAL REHABILITATION (VR) FORMTEXT ?Name: FORMTEXT ?????SSN #: FORMTEXT ?????Previous Name (if any): FORMTEXT ?????Birth Date: FORMTEXT ?????Gender:Does not wish to self-identify: FORMCHECKBOX Female: FORMCHECKBOX Male: FORMCHECKBOX Residence (street): FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip: FORMTEXT ?????County: FORMTEXT ?????E-Mail: FORMTEXT ?????Mailing Address (if different): FORMTEXT ?????Primary phone number: FORMTEXT ?????Secondary phone number: FORMTEXT ?????Primary number a cell phone: yes FORMCHECKBOX No FORMCHECKBOX Secondary number a cell phone: yes FORMCHECKBOX No FORMCHECKBOX Living Arrangement: FORMCHECKBOX Private Residence Other: FORMTEXT ?????Race/Ethnicity:American Indian /Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black or African-American FORMCHECKBOX Does not wish to self-identify FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Native Hawaiian or other Pacific Islander FORMCHECKBOX White FORMCHECKBOX Primary/Preferred Language: FORMTEXT ?????Preferred Correspondence: FORMCHECKBOX Audio FORMCHECKBOX Braille FORMCHECKBOX E-mail FORMCHECKBOX Large Print FORMCHECKBOX VideophoneDo you have a Legal Guardian? FORMCHECKBOX yes FORMCHECKBOX NoName of Legal Guardian: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Mailing Address: FORMTEXT ?????Primary Emergency Contact:Name: FORMTEXT ?????Relationship to applicant: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Mailing Address: FORMTEXT ?????Secondary Emergency Contact:Name: FORMTEXT ?????Relationship to applicant: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Mailing Address: FORMTEXT ?????Are You Registered to Vote: FORMCHECKBOX Yes FORMCHECKBOX NoIf No, would you like a voter registration form? FORMCHECKBOX Yes FORMCHECKBOX NoMarital Status: FORMCHECKBOX Divorced FORMCHECKBOX Married FORMCHECKBOX Never Married FORMCHECKBOX Separated FORMCHECKBOX WidowedAre You a United States Citizen? FORMCHECKBOX Yes FORMCHECKBOX NoIf No, do you have legal status to work in the U.S.? FORMCHECKBOX Yes FORMCHECKBOX NoWho Referred You?Name: FORMTEXT ?????Relationship to applicant: FORMTEXT ?????Agency: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Primary Source of Support FORMCHECKBOX Family/Friends FORMCHECKBOX Personal Income/Wages FORMCHECKBOX Public Support (SSI, SSDI, TANF, etc.) FORMCHECKBOX Other FORMCHECKBOX Personal Income: Interest, Dividend and rentDisability Benefits:Type of BenefitAmount ReceivedApplication StatusOther IncomePendingDeniedSourceAmountSSI-Aged$ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX General Assistance$ FORMTEXT ?????SSI-Disabled$ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Worker’s Compensation$ FORMTEXT ?????SSDI-Disabled$ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Unemployment$ FORMTEXT ?????SSDI-Other$ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Other Disability$ FORMTEXT ?????VA$ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Other (Family income, wages, etc.)$ FORMTEXT ?????TANF$ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX If you receive TANF will your benefits exhaust within two years? FORMCHECKBOX Yes FORMCHECKBOX NoMedical Insurance: FORMCHECKBOX Maine Care (Medicaid) FORMCHECKBOX Medicare FORMCHECKBOX Private through other means FORMCHECKBOX Private through own work pending FORMCHECKBOX Private through own work FORMCHECKBOX Public insurance from other sources FORMCHECKBOX None FORMCHECKBOX Not available FORMCHECKBOX State/Federal Affordable Care Act ExchangePrimary Doctor FORMTEXT ?????Date Last Seen FORMTEXT ?????Address of Primary Doctor: FORMTEXT ?????Other Sources of Medical Information FORMTEXT ?Doctor/Hospital/Clinic FORMTEXT ?????Date Last Seen FORMTEXT ?????Address: FORMTEXT ?????Doctor/Hospital/Clinic FORMTEXT ?????Date Last Seen FORMTEXT ?????Address: FORMTEXT ?????Doctor/Hospital/Clinic FORMTEXT ?????Date Last Seen FORMTEXT ?????Address: FORMTEXT ?????Doctor/Hospital/Clinic FORMTEXT ?????Date Last Seen FORMTEXT ?????Address: FORMTEXT ?????OTHER AGENCIES AND SERVICES INVOLVED AT APPLICATION FORMTEXT ?AGENCY/SERVICE FORMTEXT ?????Address: FORMTEXT ?????AGENCY/SERVICE FORMTEXT ?????Address: FORMTEXT ?????AGENCY/SERVICE FORMTEXT ?????Address: FORMTEXT ?????AGENCY/SERVICE FORMTEXT ?????Address: FORMTEXT ?????Are you working: FORMCHECKBOX Yes FORMCHECKBOX No If NO, date last employed? FORMTEXT ?????Are you requesting services to maintain your current employment? FORMCHECKBOX Yes FORMCHECKBOX NoWork History: (Please list starting with the most recent or present job and attach a resume if you have one) FORMTEXT ?Employer: FORMTEXT ?????Job Title: FORMTEXT ?????Hours per week: FORMTEXT ?????Rate of pay: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Leave Reason: FORMTEXT ?????Employer: FORMTEXT ?????Job Title: FORMTEXT ?????Hours per week: FORMTEXT ?????Rate of pay: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Leave Reason: FORMTEXT ?????Employer: FORMTEXT ?????Job Title: FORMTEXT ?????Hours per week: FORMTEXT ?????Rate of pay: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Leave Reason: FORMTEXT ?????Employer: FORMTEXT ?????Job Title: FORMTEXT ?????Hours per week: FORMTEXT ?????Rate of pay: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Leave Reason: FORMTEXT ?????Employer: FORMTEXT ?????Job Title: FORMTEXT ?????Hours per week: FORMTEXT ?????Rate of pay: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Leave Reason: FORMTEXT ?????Are you a Veteran? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been convicted of any violation of law by any court of law? Include any guilty pleas entered, military courts martial, and traffic violation convictions for Operating Under the Influence (OUI), or traffic violations that resulted in your license being suspended. FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No Were you convicted of any crimes prior to the age of 18? FORMCHECKBOX Yes FORMCHECKBOX No Do you have a criminal record outside the State of Maine? FORMCHECKBOX Yes FORMCHECKBOX No If you answered yes to any of the above three questions, please describe: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????A conviction will not disqualify you from Vocational Rehabilitation Services but will be considered in relation to your vocational goal. FORMTEXT ?Education: Do you have your diploma or GED? FORMCHECKBOX Yes FORMCHECKBOX NoYear of graduation? FORMTEXT ????If not, highest grade completed and year completed: FORMTEXT ?????Are you currently a student? FORMCHECKBOX Yes FORMCHECKBOX NoLast School you attended? FORMTEXT ?????Have you ever received services under an Individual Education Plan? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever received services under a 504 plan? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any college education, if so where? FORMTEXT ?????Total number of credits: FORMTEXT ????Area of study: FORMTEXT ?????Did you graduate from college: FORMCHECKBOX Yes FORMCHECKBOX NoLast year in attendance: FORMTEXT ????Any Specialized vocational training? If so, what? FORMTEXT ?????Have you applied for Vocational Rehabilitation before? FORMCHECKBOX Yes FORMCHECKBOX NoWhen/Where: FORMTEXT ?????Primary disability: FORMTEXT ?????Cause of disability: FORMTEXT ?????Secondary disability: FORMTEXT ?????Cause of disability: FORMTEXT ?????I hereby apply for Vocational Rehabilitation services as I believe I have a disability that interferes with my ability to work. I certify that I have access to a copy of the Maine DOL Bureau of Rehabilitation Services Rights and Responsibilities document and I understand that my vocational rehabilitation counselor is available to answer any questions I have regarding the document. I certify that to the best of my knowledge the above information is true. Failure to disclose requested information could be considered evidence of refusal to cooperate and result in closure of your case. FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?Applicant Signature FORMTEXT ?????Date FORMTEXT ?????Parent/Guardian Signature FORMTEXT ?????Date FORMTEXT ????? ................
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