CareerPoint - Providing Resources for Employers & Job Seekers

Ticket To Work Program Registration Form

If you are an SSI/SSDI Recipient and would like to register for the Ticket To Work Program, please fill out this form and click on the "Submit" button at the bottom of the page. Thank you for participating in the Ticket To Work Program.

Beneficiary General Information

Beneficiary Ticket Number: *
Beneficiary First Name: *	(First Name)
Last Name: *	(Last Name)
E-mail Address: *	if none, enter "info@careerpointma.org"
Name of Beneficiary Legal Representative:	if applicable (Last, First, MI)
Contact Address: *	(Beneficiary or Legal Representative)
City: *
State: *
Zip Code:
Phone Number:*
* Required

CareerPoint 850 High Street Holyoke, MA 01040 Tel: (413) 532-4900 Fax: (413) 532-0737