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Employment Options
Free Job Placement for SSI/SSDI Recipients Through the Ticket To Work Program
Work At Home Application
This application must be completed on a computer or laptop.
Welcome! To qualify for free job placement from Employment Options through the SSA Ticket To Work program, we will need some information from you! Please complete ALL fields and Submit the form. -- Only submit ONE form!-- Multiple forms can delay the process. Please allow at least 2 business days for us to contact you! We will be in touch soon! If you do not hear from us after 48 hours, you can call 800-441-3114 ext 754 or submit a contact us website form. Thank you!
Step 1 of 12
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Are you currently receiving SSDI or SSI benefits?*
*
SSDI (Social Security Disability Income)
SSI (Supplemental Social Security Income)
Both SSDI & SSI
SSI Retirement
None of the Above
*Once you answer question #1 about benefits and 'if' your answer meets our program guidelines, the next question will populate on the page.
Based on the answer you selected, we are unable to accept your application at this time or provide you with our free employment services.
Our applicants MUST BE currently receiving either SSDI (Social Security Disability Income) or SSI (Supplemental Security Income) (non-retirement) to apply with us, because we work in the Social Security "Ticket to Work" program.
You can email
help@myemploymentoptions.com
for a list of other job resources to help you. You will automatically get a list of resources via email auto-responder.
Best wishes,
Employment Options Staff
How Did You Hear About Us?
*
Employment Options' Careereco Job Fair Apr 11th, 2019)
SSA/TTW Blog "9 Reasons to Try Ticket to Work (April 2019)
Bender Careereco Online Job Fair March 13th, 2019
Automated Phone Call from Employment Options
Lisa Seeley Success Story
Lori Adler Success Story
Social Media
Postcard from Employment Options by Mail
Internet Search Engine
Job Fairs-Events
Job Board/Referral Websites
Personal Success Stories
Disability Resources
Social Security Administration
Employment Options
TV/Radio Station
MEO Ambassador Program
Other
Who Referred You?
Please type first and last name of who referred you or the agency or website
Social Security Administration-Maximus
*
Please also choose an answer from the Drop Down Menu Below.
Blog Article
Employee
Choosework/Ticket To Work Website
Automated Phone Call
Ticket to Work Mailing
Social Media
Disability.gov blog website
Lisa Seeley Success Story
Lori Adler Success Story
WISE Webinar Event (Monthly)
Other
*If previous answer is 'OTHER', type answer here
*
Employment Options
*
Please also choose an answer from the Drop Down Menu Below.
Our Website
Staff
E-Mail Mailing
Automated phone call
On-line Job Fair
MEO Ambassador Program
Other
*If previous answer is 'OTHER', type answer here
*
Staff
*
Referrer name
*
Social Media
*
Please also choose an answer from the Drop Down Menu Below.
Facebook
LinkedIn
Pinterest
Twitter
Youtube
Other
*If previous answer is 'OTHER', type answer here
*
Source Page (where did you see us on Social Media?)
*
City/Station
*
Job Boards/Referral websites
*
Please also choose an answer from the Drop Down Menu Below.
Ability Links
Abilityjobs.com/Job Target
Disability.gov blog
Indeed.com
Realwaystoearnmoneyonline.com (Annie)
WAHM.com
WorkathomeWoman.com (Holly)
Workersonboard.com (Alicia Washington)
Other
*If previous answer is 'OTHER', type answer here
*
Personal Success Stories
*
Please also choose an answer from the Drop Down Menu Below.
Lori Adler
Lisa Seeley
Other
*If previous answer is 'OTHER', type answer here
*
Disability Resources
*
Please also choose an answer from the Drop Down Menu Below.
Ability Links
America Works
Disability.gov Blog
Disabledpersons.com
Disability Program Navigator
Disability Program Navigator - LinkedIN group
Multiple Sclerosis Society
Hire Disability Solutions
Think Beyond The Label
Vocational Rehabilitation Services (State)
National Association of Nurses With Disabilities (NOND)
Other
*If previous answer is 'OTHER', type answer here
*
Job Fairs Online-Events
*
Please also choose an answer from the Drop Down Menu Below.
Bender Online Job Fair
Virtual Job Fair - Employment Options
Job Fair - Other
Webinars - Employment Options
Webinars - Other
Local Job Fair
Vendor Job Fair
Other
*If previous answer is 'OTHER', type answer here
*
Other
*
Please also choose an answer from the Drop Down Menu Below.
Word of Mouth
Religious Organization
Library
Other
*If previous answer is 'OTHER', type answer here
*
Benefits Form: Have You Completed our Online Benefits Screening Form Before
*
Yes, I have recently submitted a Benefits Screening form
No, I have not submitted a Benefits Screening form
I am not sure what that is
Have you recently received a letter from the Social Security Administration that they will be conducting a Medical Review?*
*
Yes, I recently received a letter
No, I have not received a letter
What state do you live in? Choose from list below.
*
Please choose your state from the drop down list.
Alabama
Alaska
Arizona
Arkansas
California
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
TIP: If the question "What State Do You Live in" populates, you must select a specific state you reside in from the drop down menu in order to see the next questions.
Based on the state you selected, we are unable to accept your application.
We are not able to serve applicants who reside in Hawaii or Alaska for reasons beyond our direct control. The jobs that we place clients in only hire in the 48 Hiring contiguous states. You can call the Ticket to Work helpline @ 866-968-7842 and ask for a list of agencies in your state.
***Washington DC residents*** Our Work At Home partners do not hire in your area. However, if you are also interested in jobs 'outside the home' in your local area, you can follow the link below to submit Submit Option #2 (On-site form).
http://dev.myemploymentoptions.com/apply-now/
***California applicants***
If you are currently receiving SSDI/ SSI benefits, you can contact one of our partners directly:
TCOE/A Ticket to Success/MOVE
Linda Patino, Regional Coordinator
Toll Free: 800.540.0307
http://www.tcoe.org/TicketToWork/
For a free job resources list, email
help@myemploymentoptions.com
. (auto-responder)
Best wishes,
Employment Options Staff
What is the highest level of education that you have completed?
*
High school diploma or GED equivalent
Some College
Two Year College Degree
Four Year College Degree or Higher
I still need to complete my high school diploma or GED
Based on the answer you selected, we are unable to accept your application at this time or provide you with our free employment services. We are not able to serve applicants who have not yet completed a high school diploma or GED because of our virtual nature.
You can call 866-968-7842 and the Ticket to Work Help Line can assist you with finding agencies that offer education resources.
You could also contact your State Department of Vocational Rehabilitation office for GED resources:
help@myemploymentoptions.com
(Automatic email will be generated to you)
Best wishes,
Employment Options Staff
Are you an existing client of Employment Options and already assigned to us?
*
Yes, I am a current client of Employment Options and have my ticket assigned here
No, I am not a client of Employment Options
You answered 'YES' that you are a current and existing client of Employment options. If you are already have your ticket assigned to us and working with a job counselor, you do not need to apply again. If you are trying to apply for one of our jobs, simply contact your assigned job counselor! They will work with you directly and go over job openings! 800-441-3114
Thank you for your cooperation!
Lori Adler
Public Relations/Technology
ladler@myemploymentoptions.com
Have you previously submitted an on-line application to Employment Options in the past?
*
Yes, I have previously submitted an online application and didn't qualify for Employment Options' service
No, I have never previously submitted an application with Employment Options prior to today.
You answered yes that you have previously submitted an online application with us and didn't qualify after our screening process. We do ask applicants who have previously applied with us and didn't qualify, to not submit a new application unless we have instructed you to.
If you feel your situation has changed since your last application, please call Shieka at 800-441-3114 ext 754 to determine if we need you to submit a new application.
Ticket to Work Resources: We are one agency out of hundreds in the Ticket to Work program! Applicants on SSDI/SSI who did not qualify with us, may be able to receive help from another Employment Network (EN) that has multiple streams of funding or through your State Dept. of Vocational Rehabilitation.
http://www.chooseworkttw.net/about-program/faq.html
For a free job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you)
Best wishes,
Employment Options Staff
Are you willing to use the guidelines of Ticket to Work and earn over $880.00 per month? (see below)
*
Yes, I am willing to earn over $880 per month, with the help of Ticket to Work
No, I am not willing to earn over $880 a month
[Per SSA website]- During a Trial work period (TWP), a beneficiary receiving Social Security disability benefits (SSDI) may 'test' their ability to work for at least 9 months and still be considered disabled. During a Trial work period, a person will still receive full Social Security benefits and health insurance, regardless of how much is earned, as long as, they report work activity. In 2019, a Trial work month is any month in which total monthly earnings are over $880. To read more about Ticket to Work & SSDI benefits, visit http://www.ssa.gov/oact/cola/twp.html
You answered SSDI. If you have worked while on benefits, have you used up 'All' of your 9 month Trial Work Period months?*
*
Yes I have used up all 9 Trial period months
No, I have not used up all 9 trial period months
I have not worked at all while receiving SSDI. Not Applicable
*If you have worked while on Social security benefits and are unsure of how many trial work period months you have used up, you can call Social Security at 800-772-1213 and ask for a BPQY (Benefits Planning Query)
If you are on SSDI & have used your nine Trial Work period months, are you willing to come off/lose your Social Security disability cash benefits? (If you currently receive medical coverage through Medicare, you can continue to be eligible for coverage for at least 93 months, the month following your Trial Work Period. Our benefits specialist can help you sort through this process.
Yes, I am willing to come off/lose my disability benefits
No, I am not willing to come off/lose disability benefits
Unfortunately, because of Ticket to Work program guidelines, we are unable to help you with our job placement services. The purpose of the Ticket to Work Program and our services is to assist you in getting off disability benefits over time and becoming self-sufficient.
You may be able to receive help from another Employment Network (EN) that has multiple streams of funding or through your State Dept. of Vocational Rehabilitation. To read more about the ultimate goals of Ticket to Work/the Work Incentives Improvement Act of 1999 visit:
http://www.chooseworkttw.net/about-program/faq.html
For a job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you)
Best wishes,
Employment Options Staff
How many hours do you want to work?
*
Full-time
Part-time
Unfortunately, because of Ticket to Work program guidelines, we are unable to help you with our job placement services. The purpose of the Ticket to Work Program and our services is to assist you in getting off disability benefits over time and becoming self-sufficient.
You may be able to receive help from another Employment Network (EN) that has multiple streams of funding or through your State Dept. of Vocational Rehabilitation. To read more about the ultimate goals of Ticket to Work/the Work Incentives Improvement Act of 1999 visit:
http://www.chooseworkttw.net/about-program/faq.html
For a job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you)
Best wishes,
Employment Options Staff
Have you ever assigned your Ticket to Work?
*
Yes
No
Do you currently receive job placement services from another employment network or State Department of Vocational Rehabilitation (VR)?
*
Yes
No
Important Reminder: You answered 'yes' to currently receiving job placement services from another EN or VR agency.
You can still complete our application. However, please note that you will have to close your VR case and dis-assign your ticket from that agency, ('if' we determine that we can help you & if you want our job placement assistance). A beneficiary’s 'ticket' to work cannot be assigned to more than one agency at a time, per Ticket to Work guidelines. (Our staff can give you instructions)
If you have worked with a State Department of Vocational Rehabilitation (VR) Agency - was closure successful or unsuccessful? (Did you find employment while with VR)?
*
Yes, I found employment with VR
No, I did not find employment with VR
I have never worked with a State Department of Vocational rehab office
We are sorry but because you successfully found employment through Vocational Rehab. (VR) and also because of how the Ticket to Work program works, we will be unable to help you with our free services. We are mandated by the rules of the program.
For a complete job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you). Within the resource email, you will find a website for finding other agencies in the Ticket to Work program, nationwide.
Best wishes,
Employment Options Staff
Are you a Veteran?
*
Yes
No
If you answered Yes to being a Veteran, were you discharged under honorable conditions?
*
Yes, I was discharged under honorable conditions
No, I was not discharged under honorable conditions?
Not applicable/I am not a Veteran
Were you referred to Employment Options by Wounded Warriors ?
*
Yes, I was referred directly by Wounded Warriors
No, I was not referred by Wounded Warriors
Do have the ability to directly connect your computer to your Internet or cable modem? ---- (DIRECT CONNECT means that you CANNOT use a router and/or a wireless technology to connect to the Internet. Your Internet cable/cord must directly connect into your computer (PC))
*
Yes, I am able to directly connect my computer to my internet/modem
No, I am not able to directly connect my computer to the internet/modem
You answered that you are unable to directly connect your internet/cable modem to your PC. NONE of our work from home employers allow wireless connections due to security concerns. Please reapply when you have resolved this issue! You can also hook your computer during work directly to your internet and then during non working hours use your router.
Thank you for your cooperation!
Employment Options Staff
LANDLINE PHONE: Do you have a land line phone line or can you get one if needed?--- NOTE: A land line phone is a traditional phone line that goes through your telephone company's lines --NOT-- over the internet. A land line phone always plugs into a wall jack NEVER the computer.**
*
Yes, I currently have a landline phone
No, I do NOT have a landline phone. -- "Yes" I am able to get one if needed.
No, I do NOT have a landline phone. -- "No" I am unable to get one if needed.
**Special Note** Most phone companies have a reduced rate for people receiving SSI or SSDI
How Old Is The Computer (Desktop or Laptop) That You Will Use When Working?
*
My computer is between 1 and 5 years old
My computer is older than 5 years
My computer is less than 1 year old
We are sorry but based on your answer, your computer is older than what our employer partners ask for and what is compatible with their specific software.
If you decide to use a different system or obtain a newer computer in the future, please feel free to return to this application and apply again at any time.
You can also send an email to
help@myemploymentoptions.com
to receive an automatic list of job resources. Within the resource email, you will find a website for other agencies in the Ticket to Work program.
Thank you for your interest in our company!
You can also send an email to help@myemploymentoptions.com to receive an automatic list of job resources
What type of 'Windows' operating system do you have at home? [MAC's, All-In-One PC's and Cell phones NOT ACCEPTABLE]*
*
Window 7
Windows 8
Windows 8.1
Vista
XP
All in One PC system
MAC (Apple) system
Cell Phone
Windows 10
*SPECIAL NOTE: Effective January 2018: Single Core Processors will NO longer be accepted.
As of spring 2016, we are no longer able to accept Work At Home applicants applying with a Windows 'VISTA' operating system.
Microsoft ended Mainstream support and most updates for VISTA well over a year ago. Many VISTA users can no longer get important security updates etc.
You are welcome to upgrade your Windows system to another version and come back and apply with us at any time.
We also offer community jobs (outside the home). You can submit Option #2 of our applications. Scroll up and click "Apply".
For referral sources, you can email
help@myemploymentoptions.com
for a list of other general resources to help you.
You can also call the' Ticket to Work Help Line) at 866-968-7842 for help finding other Employment networks.
Thank you for your interest in Employment Options!
Effective April 8, 2014, per Microsoft, tech support for Windows XP will no longer be available. Microsoft will also no longer offer automatic updates for XP which often protect your PC from viruses, spyware, and malicious software.
Therefore, because of this decision, Employment Options can no longer accept systems with XP. You are welcome to upgrade your Windows system and come back and apply with us at any time.
We also offer community placement (outside the home). You can submit Option #2 of our applications. Scroll up and click 'Job Seekers' again. Other Ticket to Work agencies, call the Help-Line: 866-968-7842.
To read Microsoft's official announcement and for tips:
http://windows.microsoft.com/en-us/windows/end-support-help
Thank you for your interest in Employment Options!
Unfortunately, All-in-One PC systems are not accepted at this time by any of our Work at Employers.
Feel free to apply at another time if you change systems. We also offer community job placement (outside the home). You can submit Option #2 of our applications. Scroll up and click 'Job Seekers' again.
For referral sources, you can email
help@myemploymentoptions.com
for a list of other job resources to help you.
You can also call the Ticket to Work Help Line @ 866-968-7842 for help finding other Employment networks besides our agency. Thank you for your interest in Employment Options!
Unfortunately, MAC systems are not a Windows based system. Our Work-at-Home Employers -Do Not- accept MAC's systems nor the use of Cell phones as a computer for working at this time.
You must have a Windows based Operating system per our Work at home Employers who are leaders in the industry. (PC). Feel free to apply at another time if you change systems. We also offer community job placement (outside the home). You can submit Option #2 of our applications. Scroll up and click 'Job Seekers' again.
For referral sources, you can email
help@myemploymentoptions.com
for a list of other job resources to help you.
You can also call the' Ticket to Work Help Line) at 866-968-7842 for help finding other Employment networks. Thank you for your interest in Employment Options!
PC SPECIFICATIONS SECTION
MINIMUM SYSTEM REQUIREMENTS: PC with a minimum 1.6 GHz processor, 2 GB RAM and 40 GB free space
What type of computer will you be using? (read note below)
*
I will be using a LAPTOP
I will be using a DESKTOP
**NOTE: Your computer 'MUST BE' directly connected to your internet to work with our employers. A computer using a wireless system like a router will not be accepted by our Employers when working.
What type of processor does your computer have?
*
Single Core (Lower than i3)
Duo Core (i3, i5 or i7)
Quad Core (i3, i5 or i7)
To locate: Go to "Control Panel" then choose "Systems"
What is your processor speed? (GHz)- (ONLY TYPE A NUMBER IN BOX- NOT- UNIT OF MEASURE)
*
To locate: Go to "Control Panel" then choose "Systems"
How much RAM do you have? (GB) (ONLY TYPE A NUMBER IN BOX- NOT- UNIT OF MEASURE)
*
To locate: Go to "Control Panel" then choose "Systems"
What is the size of the monitor that you will use for work? Many employers require specific size monitors for their software.
*
Note: TV screens are -not- acceptable.
Are you comfortable using the Internet? Know common shortcuts? Able to install software?
*
Yes
No
INTERNET SPEED TEST
Please go to
http://speedtest.myemploymentoptions.com/
and perform a speed test for your internet upload and download speeds. Please input the numbers in the corresponding fields below. Our Work at home employers request this information and you must have a specific minimum speed to use their technology.
Please input your DOWNLOAD SPEED result here. (Only input the number- do not include the MBPS unit of measure)
*
Example: If the speedtest result is 4 MBPS. You will input 4 in the answer field.
Based on the answer you provided, your internet Download speed does not meet our minimum requirement. Our employer partners provide us with specific speeds that must be in place in order to use their software.
The minimum currently is 1MBPS or greater.
You are welcome to check with your Internet provider about an upgrade and re-apply anytime on our website. To find other agencies in the program you can call the main Ticket to Work helpline @ 866-968-7842.
Best Wishes,
Employment Options Staff
Please input your UPLOAD SPEED result here. (Only input the number- do not include the MBPS unit of measure)
*
Example: If the speedtest result for Upload speed is 4 MBPS. You will input 4 in the answer field.
Based on the answer you provided, your internet Upload speed does not meet our minimum requirement. Our employer partners provide us with specific speeds that must be in place in order to use their software.
The minimum currently is 1MBPS or greater.
You are welcome to check with your Internet provider about an upgrade and re-apply anytime on our website. To find other agencies in the program you can call the main Ticket to Work helpline @ 866-968-7842.
Best Wishes, Employment Options Staff
TYPING TEST SECTION
Please copy and paste the website www.typingtest.com into a brand new browser tab. Complete the two minute typing test. Then, input your test results using Boxes #1-4 below All 4 fields must be filled in.
#1: TYPING SPEED (in Words per Minute) (WPM)
*
#2: ERRORS (Words)
*
#3: ACCURACY (%)
*
#4: ADJUSTABLE SPEED (in Words per minute (WPM)
*
Are you able to sit for 4+ hours of computer work per day?
*
Yes
No
Can you set aside regular set hours for working at home and not be distracted or interrupted during those hours?
*
Yes
No
All of the employers we work with require that a person work set hours and are W-2 positions. If you are physically or emotionally unable to work set hours, we will be unable to assist you directly.
You can also call Maximus (Ticket to Work Help line) at 866-968-7842 for help finding other Employment networks in the program as well. You can email
help@myemploymentoptions.com
for a list of other job resources to help you. You will automatically get a list of resources via email auto responder.
Thank you for your interest in Employment Options!
Are you able to hear without the assistance of a TTY relay service or other assistive methods?
*
Yes, I can hear fine and on my own without assistance
No, I cannot hear well and often/sometimes need assistance to hear
We are very sorry, but because Employment Options is an entirely Virtual company, with no face to face meetings, we are unable to properly assist deaf beneficiaries and/or those who need a relay service or interpreter.
Another Employment Network, Deaf Employment Business Solutions (DEBS), works specifically to help the deaf or hard of hearing find work in the Ticket to Work program.
http://www.debsllc.org/debstickettowork.html
There are also hundreds of Employment Networks and agencies in the Ticket to Work program. You can call 866-968-7842!
Also, for a complete job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you) Thank you for your interest in Employment Options!
Are you able to speak clearly or is it difficult for you to verbally communicate?
*
Yes, I can speak clearly and without assistance
No, I have a difficult time speaking clearly
We are very sorry, but because Employment Options is an entirely Virtual Employment network, with no face-to-face meetings and the ways we must communicate with clients, we are unable to assist those with severe speech difficulties.
There are hundreds of other Employment Networks and agencies in the Ticket to Work program. The resources email below includes a website to find other agencies. There are also hundreds of Employment Networks and agencies in the Ticket to Work program. You can call 866-968-7842 for assistance!
Also, for a complete job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you)
Thank you for your interest in Employment Options!
Are you able to read without assistive technology program (ex. Zoomtech, Jaws)
*
Yes, I am able to read and use the computer without needing assistive technology programs
No. I require the use of technology programs such as Zoomtech or Jaws to read
We are very sorry but we will not be able to assist you with our free services. Unfortunately, at the present time, none of our work-from-home partner companies have software that is compatible with Jaws and/or Zoomtech. People using Zoomtech limit their ability to work at home because the nature of the work requires employees to have 10-12 windows open at one time on their browser.
There are hundreds of other Employment Networks and agencies in the Ticket to Work program. The resources email below includes a website to find other agencies. You can also call the Ticket to Work Helpline at 866-968-7842 for assistance!
Also, for a complete job resources list, send an email to
help@myemploymentoptions.com
(Automatic email will be generated to you)
Thank you for your interest in Employment Options!
Are you also interested in jobs Outside the Home in your local community?*
*
YES- I am interested in both Work-From-Home & Jobs in my Community
NO - I am ONLY Interested in Work-From-Home
* If you answered YES, you only need to submit this form. You DO NOT need to submit a Community based job form.
Why do you want to return to work at this time? Type at least 2 paragraphs (Include how many hours a week you want to work)
*
Customer Service Experience and Work Goals
Important Work Experience Note:
The Customer Service Experience that we ask for in the next question --MUST BE-- in the last 10 years or less.
Please describe your Customer Service experience or background that you have -- that is at least 1 year or more -- from a past job or volunteer experience." (Examples of Customer Service could include cashier, tech support, sales, customer service rep, etc)
*
What is your 'Vocational Goal' for the next 3-18 months? (please read explanation below)* Type ONE brief sentence as to what you hope your long term vocational goal (kind of occupation) might be. This is very Important to us so * Please read and be precise* - This is information is also used on the Individual Work Plan that will be sent to you at a later date if you make it through the screening process
*
*A Vocational Goal is the specific 'kind' of occupation or educational goal that you plan to be doing in 3-18 months. Common examples could include (but are not limited too):
Working from home as a Customer Service rep, working in Administrative Support or a Management position, being self-employed; Other examples include working in Sales, Customer service, Administration, Vocational Counselor, marketing.
What is Your Long Term Vocational Goal?
*
Which Work at Home job on our website do you qualify for and have the most interest in? Type the MEO number.
*
To view our jobs:
http://dev.myemploymentoptions.com/job-openings/
WORK HISTORY SECTION
Are you currently working now?
*
Yes, I am currently employed
No, I am not employed at this time
What is the official disability date that you were awarded benefits from Social Security - include any back payment dates in your answer
*
Use Format: MM/YYYY - Example: 02/2008--- TIP: If you do not know your official disability award date you can call Social Security @ 1-800-772-1213 (OR) go online and create a personal "My Account" @
http://www.ssa.gov/myaccount/
When were you last employed?
*
Use Format: MM/YYYY - Example: 05/2005
Have you worked in the last 18 months?
*
Yes
No
EMPLOYER #1 NAME - Where did you work at in the last 18 months?
*
Example: XYZ, Inc. Please use the section below to completely fill out each Work history field. Please fill in the fields specifically and do not just put 'see resume.' You can still attach your resume (if you have one) as an addition to this section.
EMPLOYER #1 DATES - What dates did you work at this position?
*
Ex #1: 10/2005 to 08/2006 (or) Ex #2: 08/2006 to Present
Employer # 1 - JOB TITLE
*
Employer #1: JOB DUTIES (Description)
*
(Examples only: answered phones, took orders, responded to emails and filing records)
Employer #1 HOURS: Approximately how many hours did you work per week?
*
Example: 20 - 25 hours, 30 - 35 hours. 40 hours
EMPLOYER #1 PAY - What was your rate of pay for this job?
*
ex. $12.00 per hour
Have you worked at more than one place in the last 18 months?
*
Yes, I have worked at multiple places in the last 18 months
No, I only worked at Employer #1 in the last 18 months
EMPLOYER #2 NAME - Where did you work at in the last 18 months?
*
Example: XYZ, Inc.
EMPLOYER #2 DATES - What dates did you work at this position?
*
Ex #1: 10/2005 to 8/2006 (or) Ex #2: 8/2006 to PRESENT
Employer # 2 - JOB TITLE
Employer #2: JOB DUTIES (Description)
(Examples only: answered phones, took orders, responded to emails and filing records)
Employer #2 HOURS: Approximately how many hours did you work per week?*
*
Example: 20 - 25 hours, 30 - 35 hours. 40 hours
EMPLOYER #2 PAY - What was your rate of pay for this job?
*
ex. $12.00 per hour
Please fill in the Work history fields below. Please complete each field specifically and do not just put 'see resume.' You can still attach your resume (if you have one) as an addition to this section. Job #1 requires you to enter text in all 4 boxes fields. If you have 'never' worked, but have volunteer experience, please enter that as work history. We are unable to assist job hunters with no work history with the exception of recent college grads.
Job#1 - EMPLOYER NAME
*
Job#1 - JOB TITLE
*
Job#1 - MONTH/YEARS WORKED (Ex. 01/1998-01/2000)
*
Job#1 - JOB DUTIES*
*
(Example only: . answered phones, took orders, responded to emails and filing records)
Job#2 - EMPLOYER NAME
Job#2 - JOB TITLE
Job#2 - MONTH/YEARS WORKED (Ex. 01/1998-01/2002)
Job#2 - JOB DUTIES*
(Example only: . answered phones, took orders, responded to emails and filing records)
Job#3 - EMPLOYER NAME
Job#3 - JOB TITLE
Job#3 - MONTH/YEARS WORKED (Ex. 01/1998 to 01/2002)
Job#3 - JOB DUTIES*
(Example only: . answered phones, took orders, responded to emails and filing records)
Job#4 - EMPLOYER NAME
Job#4 - JOB TITLE
Job#4 - MONTH/YEARS WORKED (Ex. 01/1998 to 01/2002)
Job#4 - JOB DETAILS*
(Example only: . answered phones, took orders, responded to emails and filing records)
RESUME UPLOAD: If you have a Resume, please upload it here.
Accepted file types: doc, docx, pdf.
*We can only accept the following file types: doc, docx or pdf format. We understand that not everyone will have a resume. If you do not have one, simply skip this question.
Resume: If you have a Resume, you can copy and paste here (Use Plain Text format)
Have you had any judgements, charge-offs, reposessions or bankruptcies in the last 5 years?*
*
Yes
No
* If you are unsure, please go to www.annualcreditreport.com, where you can pull your credit report for free.
Do you have any ongoing or pending lawsuits that could possibly affect you returning to work? (ie. Car accident, Worker's comp., Criminal etc.)
*
Yes
No
Contact Details
Legal Name
*
First
Last
NICKNAME: If you prefer to be called by a name other than your legal name, please input here. If you do not have a Nickname, please put NONE in the field.
*
Email
*
Enter Email
Confirm Email
If you provided us with a cell phone number, are you ok with our staff contacting you via text message?
*
Yes, I give permission to contact me via texting
No, I do not want to be contacted via texting
Not applicable- I do not currently have a cell phone or I am not able to receive texts
You answered Yes to texting. Who is your Cell Phone Carrier? (ex. AT&T, Verizon, etc)
*
Phone
*
We will contact you at this number first.
What type of phone is the above number?
*
Cell phone
Home phone
Work phone
What is a secondary phone we can contact you about your application?
What type of phone is the above number?
*
Cell phone
Home phone
Work phone
Current Mailing Address
Home or Apartment Street Address
*
Address Line 2 (if more space is needed)
City
*
State
*
Zip Code
*
Please indicate which weekday and time of day is best to reach you.
*
(Please provide a business Monday-Friday)