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Workers Comp Information Request
Your Name (first last)
*
Your Email
Your Phone
Address
City, State, Zip
Are you any of the following?
Have Workers Compensation Voucher
Veteran
Injured on Workman's Comp
client of the State Department of Rehabilitation?
Receiving Unemployment?
Do You Have a workers Compensation Voucher?
Yes
NO
Would you like information about how to obtain a Workers Compensation Voucher
Yes
NO
Would you like information about customized at home training?
Yes
No
Do You want a rehabilitation counselor to contact you
Yes
No
Which Training Department would be of interest?
Auto Mechanics
Maintenance Technician
Industrial Refrigeration
Welding
How soon would you like to start school?
As soon as possible
Within 30 days
Within 60 days
Your comments, questions, or special issues
0/400 characters