Name:                 Date:

Address:

City:   State:    Zip Code:

Telephone #:    

Highest Grade of School Completed:

What is your disability?

Are you physically able to come to this office?  Yes     No

Have you ever applied to DVRS before?  Yes     No

If so, where?

When?          

Do you speak English?    Yes     No

Referred by:

Address:           

Telephone: