VR458 31711VR Application Revised(505KB)
User Manual: VR458
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Page Count: 10
DOCUMENTS REQUIRED:
PROOF OF INCOME (Include income for all household members)
PROOF OF TRIBAL MEMBERSHIP
PROOF OF SOCIAL SECURITY NUMBER
Examples: Social Security Card
PROOF OF PHYSICAL ADDRESS (P.O. BOX NOT ACCEPTED)
Examples: Utility Bill, Driver's License, Rent Receipt, etc.
PROOF OF DISABILITY
Revised 03/28/12
Cherokee Nation
Vocational Rehabilitation
Phone (918) 453-5004 Fax (918) 458-4482
vocational_rehab@cherokee.org
DOCUMENT CHECKLIST
In order to complete the application process, the applicant must provide at least one form of
documentation for each of the following areas indicated.
Examples: Social Security Award Letter, VA Award Letter, Copy of Benefit
Check, Income Verification from DHS (TANF), Pay Stubs, Letter from
Employer, etc.
Examples: Tribal Membership Card from Federally Recognized Tribe,
Letter from Agency (BIA), etc. (For Cherokee Citizens, please provide both
blue and white cards)
Examples: Medical/Psychological Records (last 3 years), School
Assessment Records (IEP)
Page 1 of 10
First Name:
Gender:
Tel./Cell Number:
Consumer Signature: Date:
Parent/Gaurdian/Rep: Date:
Voc. Rehab. Counselor: Date:
Revised 03/28/12
Physical Address:
Mailing Address:
Use of such information will be limited to purposes directly connected with the administration of my rehabilitation program.
All mandatory information is collected under the authority of the Rehabilitation Act of 1973 as amended. Failure to provide
this information may prevent the rehabilitation program from providing services in a timely manner.
Social Security Number:
Date of Birth:
CONSUMER RIGHTS AND REMEDIES
I have been advised of the availability of the Client Assistance Program (CAP) and have received a brochure explaining the
purpose of the CAP office. For assistance call 1-800-522-8224.
I understand that I may request an administrative review if I do not agree with a decision made by my counselor. An
administrative review may be requested by contacting the Cherokee Nation Vocational Rehabilitation Program Manager
verbally or in writing within 30 days of the effective date of the decision.
County:
Email Address:
How does your disability limit your ability to work or obtain employment?
Cherokee Nation
Vocational Rehabilitation
APPLICATION
Middle Initial:
Last Name:
What is your disability? And when did it occur? (Month & Year)
Alternate Number:
My signature to this document constitutes an application for rehabilitation services. In order to affect my rehabilitation, I
authorize the release of confidential information from my case file to agencies or others who have adopted regulations for
confidentiality. All information, both medical and personal, given or made available to the agency shall be held confidential.
Male
Female
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Who referred you to our office?
Have you ever applied for or received State or Tribal Vocational Rehablitation services?
If yes, When/Where?
Do you have a ticket to work?
Have you ever been convicted of a felony?
If yes, please explain:
Do you have charges pending?
If yes, please explain:
Are you a veteran?
Is disability connected?
If yes, please specify:
If yes, please specify:
Do you have a reliable vehicle? Number of Vehicles:
Marital Status:
Total number living in your home:
Name Relationship Income type
Are you or any household member receiving any other tribal benefits?
If yes, please explain:
Revised 03/28/12
Have you used any alternate names?
Cherokee Nation
Vocational Rehabilitation
List all household members with monthly income (include those with wages, VA, SSI, SSDI, TANF,
Worker's Comp, Unemployment, etc.)
Amount
Yes
No
Yes
No
Yes
No
No
No
No
No
Married
Yes
Yes
Yes
Yes
Single
Divorced
Widow(er)
Seperated
Yes
No
Yes
No
Page 3 of 10
Have you ever been defaulted on a student loan?
If Yes, list status of student loan:
(School Name)
(School Name)
(School Name)
(Job Title) (Dates MM/YY-MM/YY)
(Reason for Leaving)
(Job Title) (Dates MM/YY-MM/YY)
(Reason for Leaving)
(Job Title) (Dates MM/YY-MM/YY)
(Reason for Leaving)
Revised 03/28/12
(Ending Wages)
(Beginning Wages)
(Grade Complete/GED Certificate)
(Dates)
(Grade/Certificate Completed)
(Dates)
(Hours Completed/Course of Study)
(Dates)
(Ending Wages)
(Beginning Wages)
Technical
College/University
(1 . Employer Name)
EMPLOYMENT HISTORY
(List 3 most recent jobs)
(Beginning Wages)
(Ending Wages)
(2. Employer Name)
(3. Employer Name)
EDUCATION & WORK HISTORY
EDUCATION HISTORY
High School/GED
Yes
No
Page 4 of 10
I certify that the information I have given is true, correct, and complete to the best of my knowledge.
Revised 03/28/12
I agree to notify my Rehabilitation Counselor within 30 days, if I have a change in my expenses or
needs.
Upon notification of such changes, I understand my case will be reviewed and revised to reflect any
new information.
I understand that the information I have given will be carefully reviewed and that I might be asked to
provide proof of the answers given. Furthermore, I understand that any false statements make me
subject to prosecution for fraud. I hereby authorize the Cherokee Nation Vocational Rehabilitation
Program to make any necessary investigations to verify the information I have given.
Cherokee Nation
Vocational Rehabilitation
CONSUMER RESPONSIBILITY STATEMENT
I agree to notify my Rehabilitation Counselor within 30 days, if I have a change in my living
arrangements, address, telephone number, income, automobiles, or resources of any kind.
(Signature)
I understand that the Cherokee Nation Vocational Rehabilitation Program has 60 days from the date of
application to find me eligible or not eligible. After careful review of my full and complete application,
including the required documents, I will be notified of a decision.
(Please read carefully)
I understand if I falsified any information, services through the Cherokee Nation Vocational
Rehabilitation Program may be suspended. I understand that I will be notified of the Program's
decision and have 5 working days to respond. If no acceptable response, explaining the circumstance,
is received, services will be cancelled and all costs incurred will be my responsibilty.
I also agree to provide employment verification, to my VR counselor, once my training is complete and
an employment outcome has been achieved.
(Print Name)
(Date)
Page 5 of 10
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Have you ever been or are you currently being treated for any of these conditions?
Revised 03/28/12
Address
Cherokee Nation
Vocational Rehabilitation
HEALTH INFORMATION
Anemia or other disorders of the blood
Alcohol or substance abuse
Any other physical or mental condition not listed
Yes
Frequent dizziness, fainting, headaches, seizure, paralysis, or
stroke
A disorder of the eyes, ears, nose, or throat
No
Do you have any of the following?
Absence or amputation of any body parts
Loss of use of arms, legs, or other body parts
If yes, has it kept
you from working?
A tumor, cancer, disorder of skin or lymph glands
Allergies
Dr. Name/Facility
Condition
A mental or nervous disorder
Persistent coughing, bronchitis, asthma, emphysema,
tuberculosis, or other lung disorders
Chest pain, high blood pressure, rheumatic fever, murmur,
heart attack, or other disorder of the heart or blood vessels
Intestinal bleeding, ulcer, hernia, colitis, other disorder of
the stomach, intestines, liver or gallbladder
Disorder of kidney, bladder, prostate, or reproductive system
Diabetes, thyroid, or other endocrine disorders
Arthritis, or other disorder of the muscles or bones including
the spine, back , or joints
No
Yes
Please answer "Yes"
or "No" to all
Yes
No
Page 6 of 10
I, SS#: DOB: Record No.
Medical
Other (Specify):
Date(s) of Services:
The information shall be obtained, used or disclosed for the following purpose(s) only:
Establish eligibility for rehabilitation services
Develop a vocational program for consumer
Parent/Gaurdian/Representative:
Revised 03/28/12
Cherokee Nation Vocational Rehabilitation
P.O. Box 948
Tahlequah, OK 74465
Portions to be released (check all that apply):
Psychological
The information I authorize may include records which may indicate the presence of a communicable or non-
communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis,
gonorrhea, Human Immunodeficiency Virus, also know as Acquired Immune Deficiency Syndrome (AIDS). I
understand that these records may include psychiatric, alcohol and drug abuse information, occupation information, or
information regarding other insurance coverage. I specifically authorize the release of my drug, alcohol and/or mental
health treatment records. The information obtained with this disclosure form is required to be kept confidential by the
Cherokee Nation Vocational Rehabilitation Program under Federal Law 34CFR 361.38.
Information used or disclosed pursuant to this authorization may by subject to re-disclosure by the recipient and no longer
protected by Federal Law. However, the recipient may be prohibited from disclosing substance abuse information under the
Federal Substance Abuse Confidentiality Requirements
I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the
protected health information covered by this authorization. The entity authorized to disclose the information will not be
compensated by the recipient for the disclosure, except for the cost of copying and mailing as authorized by the law.
hereby authorize the use or disclosure of the Protected Health Information (PHI) described below to be provided
to or obtained by the following:
Name of Agency/Individual to Receive PHI:
Attn:
Name of Facility/Individual to Disclose PHI:
AUTHORIZATION FOR RELEASE OF INFORMATION
Termination date: This Authorization expires (12) months following the date signed.
Right to revoke: I may revoke this authorization by sending a written request to the Cherokee Nation Vocational
Rehabilitation Program at the address listed above. Revocation will not apply to information already used or disclosed
in response to this authorization.
Date:
Date:
Consumer Signature:
Page 7 of 10
PRINT OR TYPE
entity, C=corporation, P=partnership)
Minority Certification: (Select all if apply)
Disabled Veteran
Woman Owned
If sole proprietorship provide SSN & FEIN if applicable
OR
Federal Employer Identification No. (FEIN)
Yes (if yes, please attach a letter of explanation) No Yes No
Has your firm and/or is your firm involved in Federal debarment process?
Yes (if yes, please attach a letter of explanation) No
VEND
Addition Change
( )
Title
REMIT ADDRESS (Where check should be sent, if different than above)
PO Box or number and street
Signature
City, State, Zip + 4
Vendor Entity Type: (Select only one box)
If doing business as (D/B/A) or business name of Sole Proprietorship
Please Print
NAICS/SIC Industry Code
Code:
WHAT WILL YOU BE PROVIDING?
Goods
Services
Both
Does any owner, sales/service representative, or employee, have a personal relationship with a CN
employee (includes all tribal locations)?
TAXPAYER IDENTIFICATION NUMBER (TIN) (Provide One Only)
CERTIFICATION: Under penalties of perjury, I declare that the information I provided is correct
and complete
FOR CN USE ONLY
Industry Title: _________________
1099
Phone
Date
Corporation
Government
Other
PO Box or number and street
PRIMARY ADDRESS (For return of 1099 Form)
Contact Name:
Cherokee Nation Substitute W-9 Form
Request For Taxpayer Identification Number and Certification
Your United States TAXPAYER IDENTIFICATION NUMBER MUST be provided regardless of your tax status. Name must be the same
as that filed with the IRS or the Social Security Administration as applicable. Failure to return this form in a timely manner will delay the
order and/or payment. By Federal Law, the following information needs to be completed and returned to your procurement contact person
at Cherokee Nation.
NOTE:
LEGAL NAME
(As entered with IRS) If Sole Proprietorship, enter your LAST, FIRST, MI
TRADE NAME
Small
Small Business
(attach certificate if
Contact Name:
Contact Title:
Email Address:
Phone Number:
Fax Number:
Contact Title:
Email Address:
Phone Number:
Fax Number:
Social Security Number (SSN)
Individual/Sole
Partnership
Non-Profit
Limited Liability Company: Enter the tax classification (D=disregarded
Other Minority
Veteran
ORDER ADDRESS (Where order should be sent, if different than
PO Box or number and street
City, State, Zip + 4
City, State, Zip + 4
Cherokee Owned
Indian Owned (Tribe):
(attach certificate if checked)
(attach certificate if checked)
Page 8 of 10
Page 9 of 10
Female
Page 10 of 10
