Please return the completed form to: The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Adult Career and Continuing
Education Services-Vocational Rehabilitation
(ACCES-VR)
Application for VR Services
VR-04 (7/14)
Please print or type all entries
NAME Last First Middle Initial
GENDER
Male
Female
If you have been known by another name, enter here: Last First Middle Initial
HOME ADDRESS Street Apartment Number
City State Zip +4 Code County
SOCIAL SECURITY NUMBER
- -
If your MAILING ADDRESS is different than your home address, please complete the mailing address information below.
MAILING ADDRESS Street Apartment Number
City State Zip +4 Code County
PHONE NUMBER(S) where we can reach you or leave a message:
Best time to call
1.
2.
DATE OF BIRTH
Month Day Year
- -
Area code Area code
1. ( ) 2. ( )
Home Cell Other Home Cell Other
Email:______________________________________
Race/Ethnicity-Choose ALL that apply. If
left blank ACCES Will complete. If
Hispanic or Latino is checked, please
check additional box.
American Indian or Alaska Native
Asian (includes Indian Subcontinent)
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific
Islander
White
What is your disability? Who referred you to us? MARITAL STATUS: (Check Box)
Married Widowed Divorced
Separated Never Married
I hereby apply for rehabilitation services: Signature of applicant, parent, or legal guardian.
Date________________
X (Sign here.)
Please answer the questions below and on the back of this form.
You do not have to answer these questions now, but your answers will help ACCES-VR process your application.
Have you ever received services from ACCES-VR or its former name, the Office of Vocational and Educational Services for
Individuals with Disabilities (VESID)?..............................................................................................
Yes No
Are you now receiving services from one or more agencies? ………………………………………. Yes No
If you answered yes, indicate agency names(s), address(es) and contact person(s):
(1)
(2)
Describe how your disability limits your ability to work.