Wheels to Work Program Application

Program Application
Name*

First NameLast Name
Do you live in Otsego County, NY?*

YesNo

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Contact
Please enter a valid phone number.
Phone Type
Secondary Phone Contact
Please enter a valid phone number.
Phone Type
Date of Birth*

MonthDayYear
Date
WTW Service Requested
Household Size
Number of Adults*
Number of Children*
Under the age of 18 OR under the age of 19 and attending high school or an equivalent level of vocational/technical training
Does anyone in your household own a vehicle?*

YesNo
Make
Model
Year
Current Mileage
Is this vehicle in running condition?

YesNo
If No, Please Explain
A written estimate will be requested to confirm this information
Current Occupation
Employer Information*

Employer Name

Street Address

CityState / Province

Postal / Zip Code
Your Job Title
Hours Scheduled per Week*
Start Date with Employer

MonthDayYear
Date
May we contact your employer for a reference?

YesNo
Supervisor Name

First NameLast Name
Supervisor Phone
Please enter a valid phone number.
Transportation Needs
Miles from Home to Work*
Do you have a Valid NYS Drivers License?*

YesNo
License Number
Expiration Date

MonthDayYear
Date
Do you have children?*

YesNo

Miles from Home to Child Care Provider
Leave blank is children are not in child care outside your home
Is public transportation available in your area?*

YesNo
Do you use public transportation?

YesNo
Why not?
How do you get back and forth to work/childcare provider?
Miles from Home to Public Transportation
Leave blank is children are not in child care outside your home
Other Available Transportation Options to You

Taxi/UberCarpoolingWalkingBicycleNone of the Above
Household Income
Select Benefits You/Your Household Currently Receives.*

Family Assistance/Safety NetMedicaid/MedicareSNAP (Food Stamps)HEAPReduced/Free School LunchSSISSDINone

List all sources of GROSS INCOME (before taxes) including wages, social security benefits, public assistance benefits, child support, alimony and any other recurring income for family members:*

	Income Type	PayeeWho Receives	Amount	FrequencyWeekly/Monthly
Source 1
Source 2
Source 3
Source 4
Source 5

Please provide a brief statement explaining why you need Wheels to Work services and how it will help you obtain, maintain, and/or improve employment.*
Are you working with any other programs at Opportunities for Otsego?*

YesNo
Which OFO programs?
Please check any topics/services you'd would like additional information about:

Healthy PregnancyHeating Assistance/WeatherizationHousing AssistanceChild DevelopmentChild CareEmploymentEnergy ConservationHome visiting programsParenting EducationManaging a BudgetViolence Intervention ProgramNutrition
Please verify that you are human*

Opportunities for Otsego Wheels to Work program is only for Otsego County residents. If you do not live or work in Otsego County, reach out to our Community Advocate at 607.433.8000 for information on programs in your area.
Should be Empty:

	Name (First and Last)	Date of Birth	Living at Home(Yes or No)
Child 1
Child 2
Child 3
Child 4
Child 5

Program Application

Household Size

Current Occupation

Transportation Needs

Household Income

Opportunities for Otsego Wheels to Work program is only for Otsego County residents. If you do not live or work in Otsego County, reach out to our Community Advocate at 607.433.8000 for information on programs in your area.