APPLICATION FOR EMPLOYMENT SERVICES	For MRS office use only:
Michigan Department of Human Services	Date application received:
Michigan Rehabilitation Services
Please Print
Resident Status:	US Citizen
Non-US Citizen, type of Visa:
I. CUSTOMER DATA
NOTE: A copy of the VISA is required.
Name (Last, First, Middle Initial)	Social Security Number	Date of Birth
Address (No. & Street, Apt.)	City	County	Zip code
Area Code & Phone No.
Fax	E-mail Address
Voice	TTY
Race/Ethnicity	Hispanic	Yes	Multi-Racial	Yes	Are you a Veteran?	Yes	Sex	Male
Origin	No
No
No
Female
What is your marital Status? Married	Voter Registration Currently registered
Never Married Divorced Widowed Separated	Not registered Would like to apply Would not like to apply
Are you a previous MRS customer?	Yes (	When?	Which Office?
No
Who referred you to MRS?
Primary Disability	Cause	Limitations
Other Disability	Cause	Limitations
Are you currently under a physician’s care for your disability?	Yes (	Who is providing treatment?
No
Address
Are you currently covered by health insurance?	No	Medicare	Medicaid	Both
Yes (	Name of insurance coverage?
Do you have a Michigan driver’s license?	Yes (	Do you have a car, van or truck?	Yes	What is your means of transportation?
No
No (
What kind of job would you like and what services are you requesting from MRS?
II. SOURCES OF FINANCIAL ASSISTANCE (Which are you receiving)
Check those that apply and indicate amount	Food Stamps $	Mo.
SSI $	Mo.	Unemployment Compensation $	Weekly
SSDI $	Mo.	Workers’ Compensation $	Mo.
TANF (FIP) $	Mo.	V.A. Benefits $	Mo.
State Disability Assist. $	Mo.	Other (specify)	$
IIa. FOR SSI/SSDI “TICKET TO WORK” RECIPIENTS ONLY

Please provide a copy of your social security card, award notice letter from the Social Security Administration (SSA), and your Individual Work Plan (IWP) if working with another provider.
Type of benefit (Check both boxes if you receive both SSI and SSDI.)	Have you received a “Ticket to Work” from SSA?
SSI	SSDI	Yes	No
Are you receiving cash benefits under someone else’s SSN?	Yes, Please give name and Social Security Number
No
Have you assigned your ticket to any other provider?
No	Yes, if yes, who?

III. EDUCATION
High school diploma?	Yes	School at application	Have you earned a General Education Development Certificate (GED)?	Yes
No
No
Degree and certificates earned	Field of Study
Other training or job skills
IV. EMPLOYMENT DATA
Are you currently employed?	Yes	What types of jobs have you held in the last year?	How many jobs have you had in the past year?
No
1. Employer Name (most recent)	Address (No. & Street)	City
Dates of Employment	Wages	Reason for Leaving
Job Duties
2. Employer Name (most recent)	Address (No. & Street)	City
Dates of Employment	Wages	Reason for Leaving
Job Duties
3. Employer Name (most recent)	Address (No. & Street)	City
Dates of Employment	Wages	Reason for Leaving
Job Duties
V. PERSONAL CONTACTS
Name	Relationship	Telephone No.
Voice
Address	TTY/Fax
e-mail address
Name	Relationship	Telephone No.
Voice
Address	TTY/Fax
e-mail address
VI. MEMBERS OF YOUR HOUSEHOLD
Name	Relationship	Age	Name of Employer	Wage
1.
2.
3.
VII. CUSTOMER SIGNATURE

Your signature below means you are applying for MRS services because you wish to be employed.
Customer’s Signature (Parent or guardian, if applicable)	Date
VIII. MRS REPRESENTATIVE

The application has been reviewed, the customer has been provided an orientation to Agency services, and their rights and responsibilities have been discussed.
Signature (MRS Representative)	Date
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.

MRS-2910 (3-13) MS Word	1

Application For Employment Services - MRS-2910

Forms & Mail Management

2013-11-20

Windows User

Michigan Department of Human Services