Interest Form

Thank you for your interest in Affinity Employment Network and the Ticket to Work program.

Please note that the Ticket to Work program is only available to persons receiving SSI or SSDI.

As part of our efforts to evaluate your potential to benefit from our services and possible participation in our program, please complete this questionnaire. Please make every effort to fully and clearly answer all questions.

If you require any assistance, you may call us toll free at 1-855-879-2236. Once we receive your responses, they will be reviewed and we will follow-up with you.