Ticket to Work Interest Form for Career Seekers The Ticket to Work Program is ONLY for individuals who are: Between the ages of 18 and 64 Currently receiving monthly Social Security Disability checks Committed to looking for employment, and Interested in making more money and eventually getting off of disability cash benefits while using the protections of the Ticket to Work Program. If you meet all of the above requirements, one of our Career Coaches will contact you by phone or email to discuss next steps for participation.How did you find us?Please select all that apply. Hold the CTRL button down to select multiple answers.Letter from SSAAutomated call from SSALetter from SSAMade a call SSA Beneficiary Call Center, Received a list from the Beneficiary Call Center,ChooseWork WebsiteLocal SSA Field OfficeReferral from one of our clientsAlliance Professional Services WebsiteLetter from AlliancePhone call from AllianceJob FairWISE EventVocational Rehabilitation ReferralCommunity Partner Letter or ReferralReferral from another Employment NetworkCollege or University ReferralCareer One-StopSelf-initiated Internet SearchOther (please specify below)Other:Name* First Last City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingContact Information:Primary Phone Number Type Home Cell Office Other PhoneTime Zone Eastern Central Mountain Pacific Best Time To Call Morning Afternoon Evening Email* General Information:Are you between the ages of 18-64? Yes No Are you a Veteran? Yes No Are you currently receiving Social Security Disability Insurance (SSDI) benefits? Yes No Are you currently receiving Supplemental Security Income (SSI) benefits? Yes No Education:Are you currently enrolled in college or a technical program? Yes No Please indicate your highest level of education. Some High School GED or High School Graduate Technical School Certification Some College Associates Degree Bachelor's Degree Graduate Degree Do you have any special training, licenses, or certifications? If so, please list them.:Employment:Are you currently employed? Yes, part time Yes, full time No If currently working, what is the average gross amount you earn in a month?Please select the area that best describes your immediate interest: Work full time Work part time Work and go to school Obtain education only In what month/year were you last employed?Please tell us a little about your prior work experience. Interests:Are you interested in returning to work and becoming financially independent while utilizing services and supports to help you achieve that goal? Yes No What types of support and services are of interest to you? What type of work is of interest to you? Ticket To Work History:Have you previously participated in the Ticket to Work Program? Yes No If yes, please indicate when and to whom your Ticket was previously assigned. Is your Ticket currently assigned to an Employment Network? Yes No Have you previously received services from your State Vocational Rehabilitation agency? Yes No Other:Do you currently have reliable transportation via a private vehicle or public transportation system? Yes No Do you have Internet access? Yes No Are you comfortable using email? Yes No Would you like to participate in a Ticket Orientation Teleconference to learn more about Ticket to Work? Yes No Is there any additional information you would like to share with us?