Please complete the form below and click on the “Submit” button one time.

A representative form WorkForce Diversity will be contacting you after receiving this form.

*Please Note Ticket assignments to WorkForce Diversity are accepted on a case-by-case basis. Submittal of this form does not guarantee Ticket assignment. The form is used so that we can properly evaluate the needs of each Ticket-to-Work ticket holder in our North Central Indiana area.

  • Personal Information

  • Please fill in your full name.
  • Please provide the City and State you live in.
  • Benefits

  • What was the date that you became disabled?
  • Goals