Online Vocational Rehabilitation Services Application

Privacy Statement: The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (5USC 552a(e)(3)) require this notice to be provided to individuals when collecting personal information. The information requested on this form is necessary to properly identify the individual to ensure that the Department provides services to the correct individual. Failure to provide the information requested may result in delays in services.

Accessibility: For Information about the Accessibility of this Form, Please Review our Site Accessibility Page. If you have difficulties with this Online Vocational Rehabilitation Services Application, it is also available in an Accessible PDF Format and a Rich Text Format which can be filled out and mailed, or brought, to one of our Offices. Or it can be obtained by contacting any of the Department of Rehabilitation Offices. If you are using the correct requirements and experience any problems with this form, please E-mail the Webmaster or Call ... (916) 558-5874 ... for assistance.

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