Access Vr Application Pdf Details

Form Vr 04 is a document used to report the disposition of merchandise. The form must be completed and filed with Customs within 15 days of the export of the merchandise. This form is used to report information such as the country of origin, value, and description of the exported goods. Failure to file this form may result in civil penalties. If you are exporting goods, you will need to file Form Vr 04 with Customs. The form details information about the exported goods, including their country of origin, value, and description. Filing this form within 15 days of export will help avoid civil penalties.

Below is the details concerning the file you were looking for to complete. It can tell you the time it will need to finish form vr 04, what fields you need to fill in and a few further specific facts.

QuestionAnswer
Form NameForm Vr 04
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesacces vr application pdf, access vr application pdf, access vr application, acces vr forms

Form Preview Example

Please return the completed form to:

The University of the State of New York

 

THE STATE EDUCATION DEPARTMENT

 

Office of Adult Career and Continuing#Hgxfdwlrq#

 

Services0Yrfdwlrqdo#Uhkdelolwdwlrq#(ACCES-VR)

Application for VR Services

Please print or type all entries

 

 

 

 

VR-04 (8/11)

 

 

 

 

 

 

 

 

NAME Last

 

First

Middle Initial

JHQGHU

 

 

Male

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If your school, health, or any other

Last

First

Middle initial

records are listed under another

 

 

 

 

 

 

name, then enter the name(s) here:

 

 

 

 

 

 

MAILING ADDRESS

Street

 

Apartment Number

City

State

ZIP + 4 Code

County

SOCIAL SECURITY NUMBER

PHONE NUMBER(s) where we can reach you or leave a message

Best time to call

 

DATE OF BIRTH

 

 

1. (

)

2. (

)

1.

Month

Day

Year

Area Code

Area Code

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email : _____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race/Ethnicity – Choose ALL that apply. If left

American Indian or Alaska Native

Hispanic or Latino

 

 

blank ACCES will complete. If Hispanic or Latino

Asian (Includes Indian Subcontinent)

Native Hawaiian or Other Pacific Islander

is checked please check additional box.

Black or African American

 

White

 

 

 

 

What is your disability?

Who referred you to us?

MARITAL STATUS

1

Married

3

Divorced

 

 

 

 

 

2

Widowed

4

Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

5 Never Married

I hereby apply for rehabilitation services:

Signature of applicant, parent, or legal guardian

Date

X (sign. here)

• • • Please answer the questions below and on the back of this form. • • •

While you do not have to answer these questions now, your answers will help ACCES-VR process your application.

Have you ever received services from ACCES-VR or its former name, the Office of Vocational

 

and Educational Services for Individuals with Disabilities (VESID)?

Yes

.................................................Are you now receiving services from one or more agencies?

Yes

If you are, indicate the name(s) and address(es)

 

 

No

No

Describe how your disability limits your ability to work.

What services are you seeking from ACCES-VR?

Persons applying for or receiving rehabilitation services have the right to have any actions or decisions of this Office reviewed.

A description of the review process and form can be obtained from any ACCES-VR District Office.

Are you disabled because of a work-related injury? Do you use any assistive devices or aids?

Do you have a valid driver’s license? Do you have access to a motor vehicle? Do you use public transportation?

Are you able to leave your home?

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Check the

SSI

SSDI

 

benefit(s) you

Workers

Other

now receive

 

Compensation

Do you regularly see a doctor

Yes No

or clinic about your disability?

 

 

If ‘Yes,’ indicate date of last visit _____

Also, if you see one or more doctors or clinics about your disability, list in the box below their names and addresses.

Name and address of doctor(s) and clinic(s)

Circle the highest grade you have successfully completed, and check the applicable box(es)

1 2 3 4 5 6 7 8

9 10 11 12

GED, or High School

Elementary

High School

Equivalency Diploma

Special Education

Yes No

Do you now attend

 

 

high school?

Yes

Yes

13

14

15

16

17

20

No College

One or More

Doctorate

Years in

Graduate School

No Indicate college degree(s) earned ______________

Name and address of school you last attended

List below other people in your household

 

Full Name

Age

Their Relationship to You

 

 

 

 

 

 

 

 

List below the person or persons ACCES-VR can contact in an emergency

 

Name

Address

Phone

 

 

 

 

 

 

 

 

List below your work history (include attachments, as necessary)

 

 

Date Employed

Weekly

Job title and duties, and

 

Employer Name and Address

From

To

Earnings

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

All information will be kept confidential and is subject to verification

The State Education Department does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexual orientation, in its educational programs and activities. Inquiries concerning this of nondiscrimination at should be referred to the Department’s Office for Diversity, Ethics, and Access, Room 530, State Education Building, Albany, NY 12234.

94-98632 94-112rev cdc8/11

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