Work-n-Wheels Intake Form

Work-n-Wheels Intake Form

Additional information will be required. Please call 715-985-2391 with any questions
Today's Date*

MonthDayYear
Date
What county do you reside in?*
This program is available to residents of Buffalo, Eau Claire, Jackson & Trempealeau counties.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Do you have a valid driver's license?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home/Cell Phone*
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email Address
example@example.com
Including yourself, how many people reside in your household?*
Reason for applying:*

In need of a Vehicle LoanIn need of a Vehicle Repair Loan
Do you have any criminal/civil convictions in the past 5 years?

NoYes
If yes, please explain:
Do you have any current loans? If yes, please list all:
WDEOC can assist with direct program loans and guaranteed loans for auto purchase. This information is used solely to determine which level of program placement will best serve the applicant.
Employment

Please list your current employement
Employer Name
Your job title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your job responsibilities:
Hourly wage/salary
# of miles from home to work
Hours worked per week:
References

May be contacted to provide information if/when necessary. Relatives may be included as references.
Reference #1

First NameLast Name
Reference #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to applicant
parent, spouse, employer, etc.
Home/cell number
Please enter a valid phone number.
Reference #2

First NameLast Name
Reference #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to applicant
parent, spouse, employer, etc.
Home/cell number
Please enter a valid phone number.
Information you provide on this page of the application will not be used to determine your eligibility for the program assistance you are applying for. This information is used when this program/agency applies for additional program/agency funding and/or for the purpose of developing reports regarding program/agency services. All information provided is confidential and reports developed utilizing this information will not result in the disclosure of any applicant or participant’s identity.
Do any of these descriptions apply to you? Check all that apply.

Trouble speaking or reading EnglishEmployed but looking for a better jobUnemployedLaid off or unemployed due to a plant closing, permanent layoff or farm closureCurrently have limitation or impairment that affects getting or keeping a jobCurrently applying for Supplemental Security/Disability Insurance (SSI/SSDI)Have been a seasonal farm laborer or food processing worker within the past 2 yearsCurrently a single parent with a child under age 18 with primary custodyCurrently a single parent with a child under age 18 without primary custodyCurrently working with one or more community agency
Are you a U.S. citizen or legal alien?

YesNo
Should be Empty:

Work-n-Wheels Intake Form

Employment

References