Please Type in Your Information Below, RESAVE the Document to Your Desktop and Email The

Opportunities for Ohioans with Disabilities A P P L I C A T I O N F O R M

Type in your information below, RESAVE the document to your desktop (i.e., MYNAME.doc) and e-mail with your submission to:

OOD Finance at [email protected]

YOUR INFORMATION

FIRST NAME LAST NAME

ORGANIZATIO N

STREET ADDRESS

CITY STATE

TELEPHON ZIP CODE E

EMAIL FAX

APPLICATION CHECKLIST

Your Application must Include: Application of Organization Statement of Vision for the Interest History Interest and Opportunity Experience

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ACVREP Certifications

Ensure continuity of high quality specialized vocational rehabilitation services for individuals who are blind or visually impaired.

OOD intends to provide funding for existing or potential OOD service providers to assist their staff to obtain the following credentials to expand services areas and provide additional service options to those who are blind or visually impaired.

ACVREP - Certified Orientation and Mobility ACVREP – Certified Vision Rehabilitation Specialist Therapist # ______Total Number of Staff have the # ______Total Number of Staff have the Certification Certification # ______Total Number of Staff who Need # ______Total Number of Staff who Need Certification Certification

$______Total Amount Needed $ ______Total Amount Needed

Supporting Documentation:

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