Getting Started with ICAN

Complete this questionnaire and then click on submit. All fields marked with a red asterisk* are required.

First

Last

Date of Birth

(mm/dd/yyyy)

Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Phone Number
	Phone Number	Item weight

more items

1. 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

2. What is your current employment and training goal? Check all that apply.

Job/New Job

Career Advancement

Self-Employment

Education/Training

Social Security

Other/Unknown

Please provide details:

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.

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