"Application for Vocational Rehabilitation Services - Large Print" - Nevada

Application for Vocational Rehabilitation Services - Large Print is a legal document that was released by the Nevada Department of Employment, Training and Rehabilitation - a government authority operating within Nevada.

Form Details:

  • Released on September 15, 2017;
  • The latest edition currently provided by the Nevada Department of Employment, Training and Rehabilitation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Employment, Training and Rehabilitation.

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Download "Application for Vocational Rehabilitation Services - Large Print" - Nevada

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Nevada Department of Employment, Training and Rehabilitation
Application for Vocational Rehabilitation Services
Social Security Number
Case # (Office Use Only)
Last Name
First Name
MI
Previous Name(s)
Current Street Address
Apt
City
State Zip Code
Mailing Address (If Different)
City
State Zip Code
County
Telephone
Cell Phone
Date of Birth
(
)
(
)
Email Address
Veteran Status
Are You a US Citizen?
Not a Veteran
Yes
No
Active Service (>180 Days)
Alien Registration Card?
Active Service (≥180 Days)
Yes
No
Spouse of Veteran
Employment Authorization Document?
Does Not Wish To Disclose
Yes
No
Race / Ethnicity (At Least One)
Transition / Training (Students Only)
American Indian / Alaska Native
Current Grade Level
Asian
School Name
Black / African American
County
Hispanic / Latino
Out of State School
Native Hawaiian / Pacific Islander
(If attending a school outside of Nevada)
White
For Office Use Only - Received By:
Agency Representative
Date Received
VR Application, Large Print - Version 1.0
Page 1 of 14
Revised: 09/15/2017
Nevada Department of Employment, Training and Rehabilitation
Application for Vocational Rehabilitation Services
Social Security Number
Case # (Office Use Only)
Last Name
First Name
MI
Previous Name(s)
Current Street Address
Apt
City
State Zip Code
Mailing Address (If Different)
City
State Zip Code
County
Telephone
Cell Phone
Date of Birth
(
)
(
)
Email Address
Veteran Status
Are You a US Citizen?
Not a Veteran
Yes
No
Active Service (>180 Days)
Alien Registration Card?
Active Service (≥180 Days)
Yes
No
Spouse of Veteran
Employment Authorization Document?
Does Not Wish To Disclose
Yes
No
Race / Ethnicity (At Least One)
Transition / Training (Students Only)
American Indian / Alaska Native
Current Grade Level
Asian
School Name
Black / African American
County
Hispanic / Latino
Out of State School
Native Hawaiian / Pacific Islander
(If attending a school outside of Nevada)
White
For Office Use Only - Received By:
Agency Representative
Date Received
VR Application, Large Print - Version 1.0
Page 1 of 14
Revised: 09/15/2017
Contact Name and Telephone Number
Enter the contact information for someone whose phone number is different than
yours and who would give you a message.
Name
Relation
Phone
Name
Relation
Phone
Enter the contact information for someone NOT living in your home.
Name
Relation
Phone
Language Abilities (Check One For Each Option)
English Reading
Functional
Limited
Unknown
English Speaking
Functional
Limited
Unknown
Primary Language
Gender
Male
Female
Doesn't Wish To Self-Identify
Who Referred You?
Social Security or Disability Determination Services
Law Enforcement, Correction or Court System
University, College, Technical or Vocational School
Grade School or High School
Job Connect or Worker's Compensation
Self-Referral, Friend or Family
Veteran's Administration
Doctor, Hospital or Mental Health Facility
Rehabilitation Program in Your Community
Welfare or Public Assistance Agency
VR Application, Large Print - Version 1.0
Page 2 of 14
Revised: 09/15/2017
Current Living Arrangement
Private Residence (Home, With Family or Roommate)
Mental Health Facility
Substance Abuse Treatment Center
Group Home
Nursing Home
Halfway House
Rehabilitation Facility
Jail / Adult Correctional Facility
Homeless or Shelter
Other
Marital Status
County Served In
Single
Divorced
Carson City
Lincoln
Married
Widowed
Churchill
Lyon
Separated
Clark
Mineral
Voting Status
Douglas
Nye
Currently Registered
Elko
Pershing
Not Eligible
Esmeralda
Storey
Not Interested
Eureka
Washoe
Want to Register to Vote Today?
Humboldt
White Pine
No
Yes
Form #
Lander
Household Information
Gross Monthly Family Income
$
Parents Monthly Income (If Under Age 18)
$
Total Number in Family / Household
Total Number of Dependents in Family
VR Application, Large Print - Version 1.0
Page 3 of 14
Revised: 09/15/2017
Household Information - Continued
Name
Age
Relation
Occupation
Name
Age
Relation
Occupation
Name
Age
Relation
Occupation
Name
Age
Relation
Occupation
Name
Age
Relation
Occupation
Primary Source of Income
Personal Income (Earnings, Interest, Dividends, Rent)
Spouse's Income or Support From Family and Friends
Public Institution - Tax Supported
Public Support (SSDI, SSI, TANF, etc.)
Annuity or Non-Disability Benefit
Private Relief Agency
Worker's Compensation
Medical Insurance
Medicaid
Medicare
Not Yet Eligible
Public Insurance From Other Sources
Private Insurance Through Own Employment
Private Insurance Through Other Means (Spouse / Parent)
State or Federal Affordable Care Act Exchange
Insurance Company
SSDI (Social Security Disability Insurance) or SSI (Supplemental Security Income)
Not an Applicant
SSDI
SSI
Denied Benefits
SSDI
SSI
VR Application, Large Print - Version 1.0
Page 4 of 14
Revised: 09/15/2017
SSDI (Social Security Disability Insurance) or SSI (Supplemental Security Income)
Allowed Benefits
SSDI
SSI
Application Pending
SSDI
SSI
Benefits Terminated
SSDI
SSI
Unknown
SSDI
SSI
Are You Receiving Any of the Following? If Yes, List Monthly Amount
SSDI (Social Security Disability Insurance)
$
SSI (Supplemental Security Income)
$
TANF (Temporary Assistance to Needy Families)
$
General / Public Assistance
$
Veteran's Disability Benefits
$
Worker's Compensation
$
Any Other Type of Public Support (Please Specify)
$
Identification: Please Provide Verification for the Following Identification
List A: Provide One Item From This List
United States Passport
Certificate of United States Citizenship
Certificate of Naturalization
Alien Registration Card With Photograph
Unexpired Foreign Passport With Attached Employment Authorization
OR
Lists B and C: Provide One Item From List B AND One Item From List C
State Issued Driver's License or State ID Card With Picture and
(Name, Sex, Birthdate, Height, Weight and Eye Color)
US Military ID Card
AND
Original Social Security Card to be Witnessed at Intake
Birth Certificate Issued State, County or Municipal Authority
Unexpired INS Employment Authorization
VR Application, Large Print - Version 1.0
Page 5 of 14
Revised: 09/15/2017
Page of 14