Complete this questionnaire and then click on submit. All fields marked with a red asterisk* are required. You must have JavaScript enabled to use this form. Full Name (first & last) * Date of Birth (mm/dd/yyyy) * Phone Number (including area code) * Mailing Address Email Address Are you working with any ICAN partners? List all that apply. Capstone Community Action Community Kitchen Academy (Vermont Foodbank) Vermont Adult Learning Vermont Association of Business Industry & Rehabilitation Vermont Department of Labor VocRehab By checking the box below, I certify that: * I authorize ICAN team members to communicate and disclose information pertaining to my eligibility for 3SVT benefits and my participation in ICAN to one another for the purpose of determining the services that I need.