Vocational Rehabilitation Representative

OKLAHOMA DEPARTMENT OF REHABILITATION SERVICES

VOCATIONAL REHABILITATION AND VISUAL SERVICES APPLICATION Name SSN

Home Phone Number Cell Phone Number

Home Address City, State, Zip

Email Address

What is your disability?

Onset of Disability Male Female Date of Birth:

Describe how your disability impairs your ability to work (or to live independently)? I am interested in assistance in obtaining employment I am interested in assistance in keeping the job I have For individuals age 55 or older who are blind or visually impaired please check your preference: I am not interested in working, however I am interested in assistance in living independently What type of employment are you interested in, and how can we help you achieve your goal? Have you ever applied for rehabilitation services? yes when? no Do you receive SSI or SSDI Benefits? yes no

Have you ever been convicted of a felony? yes no

Have you ever defaulted on a student loan? yes no

My completion of this document and the completion of the initial interview process with DRS staff constitutes an application for Rehabilitation Services. In order to effect my rehabilitation, I authorize the release of confidential information from my case file to agencies or others who have adopted regulations for confidentiality. All information both medical and personal given or made available to the agency shall be held to be confidential. Use of such information will be limited to purposes directly connected with the administration of my rehabilitation program. All mandatory information is collected under the authority of the Rehabilitation Act of 1973 as amended; Title 56, Oklahoma Statute 1971, sections 328 through 330 and Title 51 Oklahoma Statute 1985, Section 24A.1 through 24A.18. Failure to provide this information may prevent the rehabilitation agency from providing services in a timely manner. Otherwise, information will not be disclosed to any individual, agency or organizations without my written consent or that of my parent, guardian or representative as applicable.

I attest under penalty of perjury that I am (check one of the following) A Citizen or national of the U.S. A Lawful Permanent Resident An Alien authorized to work Information provided is subject to verification through the Social Security Administration. Client Date

Parent/Guardian/

Representative Date

REV DATE 5/2015 DRS-C-1

DRS-C-1, PAGE 2

VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES

(56 O.S. § 71)

Statement Under Penalty of Perjury

(12 O.S. § 426)

I (D.O.B.), hereby state as follows:

(Applicant)

I am a United States Citizen.

I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct. Date County

[Signature of Applicant]

I (D.O.B.), hereby state as follows:

(Applicant)

I am a qualified alien under the federal Immigration and Naturalization Act, and I am lawfully present in the United States.

I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct. Date County

[Signature of Applicant]

REV DATE 5/2015 DRS-C-1

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