Click for Print Application APPLICATION FOR SERVICES Personal Information Birthdate Race CaucasianAfrican AmericanHispanicAsian/Pacific IslanderAmerican Indian/Alaska NativeOther Have you ever served in the Armed Forces? YesNo Highest level of education (check one) Some High SchoolHigh School DiplomsHGEDSome CollegeCollege DiplomaOther Employment Status Status Never workedNot working but have worked in the pastCurrently working part timeCurrently working full timeRetiredSupportive employment/sheltered employmentOther Disability Status Have you ever been a client of DORS? YesNo If yes, list counselor's name and phone number: Emergency Contact Screening form Date referral sent to staff: How did you hear about Resources for Independence? ---FriendRelativeDORSSocial Worker/AgencyNewspaperOther
