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Independence, Inc.
Lawrence Independent Living Resource Center 
Serving People with Disabilities Since 1978  

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Application for the
Vocational Certification
Program

Name:

Address:

Phone Number:

Email:

Would you like to sign up for the Independence, Inc. monthly newsletter?

Yes
No
I already receive it

Are you on SSI? SSDI?

Yes
No

Are you receiving Medicaid?

Yes
No

Are you on VR?

Yes
No

Have you received your Ticket to Work yet?

Yes
No


Program Applied For
(you may only enroll in one)

Information Technology Careers I 

(Meets Saturdays, 12:00 - 4:00, January 20 - May 12)

Office Assistant  

(Meets Tuesdays through Fridays, 8:30 - 10:20, January 16 - May 18)


Please make sure that you have included your email address and that it is correct.

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