Request for DVR Application

This form is voluntary. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m), Wisconsin Statutes].

You are not required by law to provide this information and there is no legal penalty if you choose not to complete this form. However, the Division of Vocational Rehabilitation (DVR) may not be able to provide the goods and services as part of an employment plan if we do not have this information. Provision of your Social Security Number is voluntary; not providing it could result in an information processing delay.

If you are under 18, or have a court-appointed guardian, you must have your guardian's permission to apply for DVR services. Their signature will be required on the completed application form.

NOTE: Only alphanumerics, hyphens, periods, @, and spaces are allowed as valid input.

Last Name:
First Name:
Middle Initial:
Social Security Number:
Date of Birth:	/ /

Impairment (Check all that apply):

AIDS/HIV	Alcohol or Other Drug Disorder
Amputation	Arthritis
Attention Deficit Disorder	Autism
Back Injury	Blindness or Visual Impairment
Brain Injury	Cancer
Carpal Tunnel(Repetitive Use Syndrome)	Cerebral Palsy(CP)
Cystic Fibrosis	Deaf or Hard of Hearing
Deaf - Blind	Depression
Diabetes	Epilepsy
Fibromyalgia	Heart Disease
Hemophilia	Hip/Knee/Other Joint Dysfunction
Kidney Failure	Mental Illness
Cognitive Disability	Missing or Deformed Limb
Multiple Sclerosis	Muscular Dystrophy
Myofascial Disorder	Paraplegia or Quadriplegic
Post Traumatic Stress Disorder	Respiratory/Pulmonary/Allergies
Severe Arthritis	Specific Learning Disability
Spinal Cord Injury	Stroke
Other	Unknown
Other - Please Explain	Unknown - Please Explain

 

Way to contact you:	E-Mail Mail Other Telephone
Other Contact Method:
Street Address:
Street Address:
City:
State:	Wisconsin Alabama Alaska Arizona Arkansas California Canada Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands
Zip Code:	-
County:	Adams Ashland Barron Bayfield Brown Buffalo Burnett Calumet Chippewa Clark Columbia Crawford Dane Dodge Door Douglas Dunn Eau Claire Florence Fond du Lac Forest Grant Green Green Lake Iowa Iron Jackson Jefferson Juneau Kenosha Kewaunee La Crosse Lafayette Langlade Lincoln Manitowoc Marathon Marinette Marquette Menominee Milwaukee Monroe Oconto Oneida Out of State Outagamie Ozaukee Pepin Pierce Polk Portage Price Racine Richland Rock Rusk Sauk Sawyer Shawano Sheboygan St Croix Taylor Trempealeau Vernon Vilas Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood
Telephone Number:	-
Messages Telephone Number:	-
E-mail Address:
Preferred Service Location:	Adams Ashland Barron Bayfield Brown Buffalo Burnett Calumet Chippewa Clark Columbia Crawford Dane Dodge Door Douglas Dunn Eau Claire Florence Fond Du Lac Forest Grant Green Green Lake Iowa Iron Jackson Jefferson Juneau Kenosha Kewaunee La Crosse Lafayette Langlade Lincoln Manitowoc Marathon Marinette Marquette Menominee Milwaukee Monroe Oconto Oneida Outagamie Ozaukee Pepin Pierce Polk Portage Price Racine Richland Rock Rusk Sauk Sawyer Shawano Sheboygan St Croix Taylor Trempealeau Vernon Vilas Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood
Accommodation:	ASL Interpreter Audio Taped Communications Braille Hmong Large Print Other Spanish
Other Accommodation:
Comments:

DVR-13100-E