Request For Application

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Request for Vocational Rehabilitation Application

Thank you for your interest in applying for the services offered by the State of Nevada, Bureau of Vocational Rehabilitation or Bureau of Services to Persons Who are Blind or Visually Impaired. If you need assistance in filling out this form, please call (702) 486-5230 in Southern Nevada; (775) 823-8112 in Northern Nevada; or TTY number at (775) 687-5353. Otherwise, please proceed in completing the form. After you complete this form an application will be emailed to you at the email address you provide on this form. Please note: the email containing the application will be from a DocuSign email address, providing the opportunity to complete and sign your application digitally from your computer, tablet or smart phone.

Name(Required)

First Last

Email(Required)

Phone(Required)

Are you a minor or under the age of 18?(Required)

Are you your own legal guardian?(Required)

Parent/Legal Guardian’s Name

Parent/Legal Guardian’s email address:

Are you still in high school?(Required)

What high school do you attend?

Are you seeking a sub-minimum wage certificate to work in sheltered employment?(Required)

Who referred you to Vocational Rehabilitation?(Required)

List any needed accommodation here

Other Comments

If you have any questions about applying, please call: (775) 823-8112 if in the Northern part of the state or (702) 486-5230 if in the Southern part of the state.

1+1=?(Required)

Email

This field is for validation purposes and should be left unchanged.

Contact Us

Northern Nevada

1325 corporate blvd

775-823-8100

mcdorangricchia@detr.nv.gov

Southern Nevada

3016 W Charleston Blvd #200

702-486-5230

TMBourke@detr.nv.gov

Nevada Relay

711