Programs & Services

Ticket to Work Questionnaire

* = Required Field

*Date:

*Name:

*Address:

*City:

*State:

*Zip:

Date of Birth:
(ex: 01/23/1945)

*Home Phone:
(ex: 123-456-7890)

*Cell Phone:
(ex: 123-456-7890)

*Email:

How did you get our number:

*Which type of Disability are you on: SSDI SSI Unsure

What is the amount of your monthly check? SSDI SSI

When did you become entitled:?
(ex: 01/23/1945)

Do you receive Medicare/Medicaid: Medicare? Medicare Medicaid

Are you in overpayment to Social Security? Yes No

Do you receive any additional state or federal aid? Yes No

Please describe the type of federal or state aid you receive:

Have you received a Ticket to Work? Yes No

Have you ever been convicted of a felony or have you had any judgments against you? Yes No

Please describe the felony conviction:

What is your education level? GED College Courses College Degree Trade School Grad Courses Describe any certifications you have:

*Have you worked in the past 18 months? Yes No

Please describe this job:

Last date of employment: FROM: THROUGH:

Last Employer:
(ex: 01/23/1945)

*What type of transportation do you have? Public Drive Self Others Drive

*Do you wish to work full-time or part-time? Full-time Part-time Part-time to Full-time

What type of job do you wish to pursue?

Do you have experience in this industry? Yes No

What is the nature of your disability?

©2013 Goodwill Keystone Area

Home | About Us | Business Services | Programs & Services | Shop | Donate | News & Events | Jobs at Goodwill | Contact Us

GII | shopgoodwill.com | Community Partners | Foundation | Facebook | Sitemap