Ticket to Work Interest Form
*
1.
First Name:
(Required.)
*
2.
Last Name:
(Required.)
*
3.
Email:
(Required.)
*
4.
Telephone:
(Required.)
To be eligible for the Ticket to Work program you must select yes for one of the following two questions. If you are unable to select yes to receiving either SSI or SSDI, please consider reviewing other CSHP programs and services.
5.
Are you currently receiving Supplemental Security Income (SSI) because of a disability?
Yes
No
6.
Are you currently receiving Social Security Disability Insurance (SSDI)?
Yes
No
*
7.
Are you a Hillsborough county resident?
(Required.)
Yes
No
*
8.
Are you a Pinellas county resident?
(Required.)
Yes
No
*
9.
Are you between the ages of 18 - 64?
(Required.)
Yes
No
*
10.
Were you employed in the last year?
(Required.)
Yes
No
11.
How did you learn that disability services were available at CareerSource Hillsborough Pinellas?
