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.

Request for Vocational Rehabilitation Form

Are you a minor or under the age of 18?*

This field is required.

Are you your own legal guardian?*

This field is required.

Parent/Legal Guardian’s Name

Parent/Legal Guardian’s email address:

Are you still in high school?*

This field is required.

What high school do you attend?

Are you seeking a sub-minimum wage certificate to work in sheltered employment?*

This field is required.

Who referred you to Vocational Rehabilitation?*

This field is required.

List any needed accommodation here

Other Comments

Your Name*

Your Email Address*

Your Phone Number*

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.

Request for Vocational Rehabilitation Application

Request for Vocational Rehabilitation Form

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