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First Name Last Name
E-Mail
Organization
Business Mailing Address:
Street
City State Zip Code
Telephone # TDD# Fax #
Please Check The Appropriate response below:
CRC Certification # (if applying for CRC credit)
Ethnicity:
African American American Indian Pacific Islander Hispanic Caucasian Asian Not listed
Highest Degree:
High School Graduate Associate's Degree Bachelor's Degree Master's Degree Doctorate M.D. Other Education
RSA Position Titles:
VR Administrator VR Counselor VR Other Direct Service Staff VR Facitlity-based Staff VR CAP Staff VR CIL Staff VR American Indian Rehab Professional Staff VR other Staff CRP Administrator CRP Direct Service Voc Staff CRP Independent Living Staff CRP Other Staff Other Positions
Age:
Under 35 years 35 - 44 years 45 - 54 years 55 - 64 years 65 and up
Gender:
Male Female
Veteran Status:
Veteran Non Veteran
Do you have a disability?
Yes No
Do you require accommodations to fully participate (check or leave blank)
Please indicate all necessary accommodation needs required for your participation :
Accommodation Needs:
(Individuals are responsible for communicating accommodation needs by the registration deadline to assure accessibility availability or alternative formats.)
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