Application for ABIL Employment Services

Thank you for your interest in ABIL Employment Services and the Ticket to Work program.

Please 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 services and possible participation in our program, please complete this questionnaire. Please make every effort to fully and clearly answer all questions.

If you require any assistance you may contact Tamara at 602-443-0701. Once we receive your responses, they will be reviewed and we will follow-up with you.

* You are required to answer fields with an asterisk (*).

Last Name: *

First Name: *

MI:

Date:

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Email Address:

Date Last Worked:

Date of Birth:

1. Are you currently working with Arizona Vocational Rehabilitation Services?: *

YES

2. Have you ever been convicted of a felony? : *

YES

If yes, Please Explain:

3. What services do you feel you will need as you seek to return to work?: *

4. What are your career goals? (I.E. Job or occupation you are seeking).: *

5. Salary Expectation?:

6. Hours per Week?:

Full Time:

YES

Part Time:

YES

7. Does your disability limit or restrict the types of work you can do?: *

YES

Please Explain:

8. What is your disability and how do you think it affects your ability to work?: *

9. Please indicate the monthly amount of your Social Security Benefit:

10. What other sources of income do you receive?

Long Term Disability:

Workers Comp.:

Other:

11. Do you have a valid Drivers License?: *

YES

12. Do you have a working Vehicle? :

YES

13. If no, how will you get to work?:

14. What is the Highest Level of Education you completed?:

15. If you have special training or a College Degree, what field is it in?:

16. List any Licenses or Certifications received and if they are current.:

17. Employment Information

In 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:

From:

To:

Responsibilities:

Reason for Leaving:

Employer 2

Employer Name:

Position/Job Title:

From:

To:

Responsibilities:

Reason for Leaving:

Employer 3

Employer Name:

Position/Job Title:

From:

To:

Responsibilities:

Reason for Leaving:

Employer 4

Employer Name:

Position/Job Title:

From:

To:

Responsibilities:

Reason for Leaving:

Employer 5

Employer Name:

Position/Job Title:

From:

To:

Responsibilities:

Reason for Leaving:

Employer 6

Employer Name:

Position/Job Title:

From:

To:

Responsibilities:

Reason for Leaving:

18. If you have ever been let go (terminated) from any position please explain.:

19. Briefly explain any gaps in your previous work History.:

20. Comments:

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Application for ABIL Employment Services

Help ABIL continue its goal of independent living for people with disabilities.

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Upcoming Events

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Information

Virginia G. Piper
Sports & Fitness
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Empowerment
Center

Application for ABIL Employment Services

Help ABIL continue its goal of independent living for people with disabilities.

Send this site to a friend

Follow us on

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Upcoming Events

Meeting SpaceInformation

Virginia G. PiperSports & FitnessCenter

DisabilityEmpowermentCenter

Meeting Space
Information

Virginia G. Piper
Sports & Fitness
Center

Disability
Empowerment
Center