Program Application
Name
*
First Name
Last Name
Do you live in Otsego County, NY?
*
Yes
No
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Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
Please Select
Home
Cell
Work
Secondary Phone Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
Please Select
Home
Cell
Work
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
WTW Service Requested
Please Select
Car Repairs
DMV Fees (e.g. Registration, Title)
Insurance Premium
Gas Card
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?
*
Yes
No
Make
Model
Year
Current Mileage
Is this vehicle in running condition?
Yes
No
If No, Please Explain
A written estimate will be requested to confirm this information
Current Occupation
Employer Information
*
Employer Name
Street Address
City
State / Province
Postal / Zip Code
Your Job Title
Hours Scheduled per Week
*
Start Date with Employer
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
May we contact your employer for a reference?
Yes
No
Supervisor Name
First Name
Last Name
Supervisor Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Transportation Needs
Miles from Home to Work
*
Do you have a Valid NYS Drivers License?
*
Yes
No
License Number
Expiration Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have children?
*
Yes
No
Provide Child Information Below
Rows
Name (First and Last)
Date of Birth
Living at Home(Yes or No)
Child 1
Child 2
Child 3
Child 4
Child 5
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?
*
Yes
No
Do you use public transportation?
Yes
No
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/Uber
Carpooling
Walking
Bicycle
None of the Above
Household Income
Select Benefits You/Your Household Currently Receives.
*
Family Assistance/Safety Net
Medicaid/Medicare
SNAP (Food Stamps)
HEAP
Reduced/Free School Lunch
SSI
SSDI
None
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:
*
Rows
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?
*
Yes
No
Which OFO programs?
Please check any topics/services you'd would like additional information about:
Healthy Pregnancy
Heating Assistance/Weatherization
Housing Assistance
Child Development
Child Care
Employment
Energy Conservation
Home visiting programs
Parenting Education
Managing a Budget
Violence Intervention Program
Nutrition/Food Insecurity
Please verify that you are human
*
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Opportunities for Otsego Wheels to Work program is only for Otsego County, NY residents. If you do not live or work in Otsego County, reach out to our Community Advocate at 607.433.8005 or ofoinc.org/contact-us for information on programs in your area.
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