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. Call us with questions at 1-800-604-8897.
Name*

First NameLast Name
Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
What is your highest level of education?
What benefits you are receiving?
What are your career goals?
How many hours per week do you want to work?
How do you get around?
What was your most recent job? When we talk, we can talk more about the kinds of work you've done.
1. Job Title
from

MonthDayYear
to

MonthDayYear
How many hours did you work per week?
Duties
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 counselingLocal job searches and leads provided to you (i.e. job placement)Benefits counseling to help you keep your benefits while workingResume` guidance and help drafting or updating itInterviewing advise and role-playing
Any other services not mentioned above? Any comments or questions?
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