Native American Outreach Application for Services

DIVISION OF VOCATIONAL REHABILITATION FLORIDA DEPARTMENT .

I am a person with a mental or physical impairment that interferes with my ability to work. I want to learn more about the rehabilitation services available through the Division and how they can assist in securing or retaining employment.

Full Name:
Social Security Number:
Date of Request:
Email:
Address:
City/State/ZIP:
Date of Birth/Sex:
Phone Number Where you can be reached:
Name of a contact person:
Phone Number of contact person:
What prevents you from working?:
Do you require any accommodation for your impairment? If yes, please explain:
If referral is by an agency or other person,

                                      Name:     Robert "Soaring Eagle" DeLong
Address of Agency or Person:Native American Outreach Program
                            322 Orchis Road
                            St. Augustine, FL.  32086
Telephone Number: Home Office - 904-797-4540
                  Cell Phone -  904-874-0988
                  Cell Phone -  904-347-4504
                  Cell Phone -  904-501-1938

Referred persons for vocational rehabilitation have the right to be interviewed and provided an explanation in the event the application is denied or is not acted upon with reasonable promptness. Services, financial aid and other benefits under the Vocational Rehabilitation program are provided on a non-discriminatory basis as required by Title VI of the Civil Rights Act of 1964. Individuals have the right to file a complaint with the Florida Division of Vocational Rehabilitation or the Rehabilitation Service Administration of the United States Department of Education if they believe that the discrimination is being practiced in the program on the basis of sex, race, color, religion, national origin, age, marital status, political affiliation, disability, or veteran status.

HOME