Ticket to Work Inquiry Form

Offices of Ticket to Work Services

1-800-604-8897

fax: 860-651-8710

www.tickettoworkservices.com

ssachs@tickettoworkservices.com
Inquire or Sign Up

By filling out our form you can begin exploring if we are the right Employment Network for you. We can help you decide. If the answer is yes, the next step will be to write up a plan that spells out the services we will provide to help you successfully return to work. Please note that filling out our form does not automatically enroll in the Ticket to Work Program. An agreed upon plan (called an Individual Work Plan) that we both sign, is needed for that to happen. This is a free and voluntary program. You can enter or leave it at any time. Call us with questions at 1-800-604-8897.
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *
Alternate Number
E-mail *
Date of Birth *

Month Day Year Date Picker Icon
Gender *
What is your highest level of education? *
What is your degree in?
What benefits you are receiving? *
Date you started receiving benefits

Month Day Year
Date Date Picker Icon
How much are you receiving in benefits? *

Under $800 $801 - $1100 $1101 - $1800 Over $1801 I am not receiving cash benefits currently
List any current licenses or certifications
What are your career goals? *
How many jobs have you held in the last 15 years? *
How much would you like to earn per month to start? *
What is the most per month you hope to earn? *
How many miles are you able to commute to work? *
How many hours per week do you want to work? *
How do you get around? *
Let's review your work history in the last 15 years, starting with your most recent job.
1. Job Title
from

Month Day Year Date Picker Icon
to

Month Day Year Date Picker Icon
How many hours did you work per week?
Duties *
2. Job Title
from

Month Day Year Date Picker Icon
to

Month Day Year Date Picker Icon
How many hours did you work per week?
Duties
3. Job Title
from

Month Day Year Date Picker Icon
to

Month Day Year Date Picker Icon
How many hours did you work per week?
Duties
Now a little bit about your disability and any work-related limitations
What is your disability?
Describe any work-related limitations from your disability.
Please list medications you are taking.
It is not necessary to provide this information if you do not wish to
Your Weight
Your Height
Just a few more quick questions...
Check all that apply *

I previously assigned my ticket with another Employment Network. I have received services from a State Vocational Rehabilitation Agency. I have worked while receiving Federal Cash Benefits from Social Security. My Federal Cash Benefits were stopped or reduced to $0.00 due to earnings. I've used some or all of my Trial Work Period. None of the above
Let us know what services you want us to provide to you *

Career counseling Local job searches and leads provided to you (i.e. job placement) Benefits counseling to help you keep your benefits while working Resume` guidance and help drafting or updating it Interviewing advise and role-playing
Any other services not mentioned above? Any comments or questions?
You can leave us a voice message with questions or concerns
Thank you for taking the time to complete our inquiry form. We will review it promptly and give you a call to see if together we can help you achieve success in returning to work.

Steven Sachs, PhD, CEO
Offices of Ticket to Work Services, LLC

Phone: (800) 604-8897 Fax: (860) 651-8710
Should be Empty:

Inquire or Sign Up