New Jersey Division of Vocational Rehabilitation Services
Confidential Referral Form

The Great Seal of the State of New Jersey

Vocational Rehabilitation Agencies assist individuals with disabilities to prepare for, obtain and/or keep suitable jobs. The rehabilitation services the agency can provide depend on the availability of State and Federal funds and on the availability of other programs and services. All individuals have the responsibility to: participate financially in their plan to the best of their ability; obtain services only with prior written approval; cooperate by using community services when they can be of help in the rehabilitation program; maintain regular contact with the VR agency counselor; and, go to work when the VR program is completed.

Please fill out information below
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(MM/DD/YYYY)
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(MM/DD/YYYY)
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(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
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(333)333-3333
yourname@abc.com
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(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
yourname@abc.com

(** indicates a required field)

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