JHM Application Referral Form for Wheels for Women Vehicle Program

Application for Referral

Wheels for Women Vehicle Program
Join Hands Ministry understands that transportation is necessary in a rural area such as Perry County, PA. To help address this problem Join Hands Ministry has partnered with Wheels for Women, a non-profit organization that exists to provide women in need of reliable transportation to find or maintain employment, access healthcare appointments, and feed their children. Wheels for Women serves three counties, limiting the vehicles available per county.

What the applicant needs to know:
- Must be a Perry County Resident
- The vehicle provided will be 5 years old or older, will have high mileage and no choice of make or model or color will be available
- Join Hands Ministry does not administer this program
- Join Hands Ministry is strictly a referral source for this program
- Join Hands Ministry does not guarantee any vehicle will be provided
- Wheels for Women decides who receives a vehicle
- Women only are considered for receiving a vehicle
- Applicant must be able to demonstrate ability to afford car insurance, registration and maintenance
- Applicant must have a valid driver's license with a Perry County address
How does an applicant apply?
- Preferably, another Perry County agency would complete this application on the applicant's behalf
- Complete the entire application
- All partial applications will not be considered, no exceptions
- Referring agency will be contacted for verification
- All verfied applications will be forwarded to Wheels for Women
What to Expect?
- Wait......
- This is NOT a fast process
- If Wheels for Women approves the applicant's application; that individual will be contacted by Wheels for Women
- At this point, Join Hands Ministry is no longer involved and can not provide any information to the applicant on their status of the application
- Sending emails or calling Join Hands Ministry will not change the status of your application
- Again, Join Hands Ministry is no longer involved in any capacity and can not help the applicant or answer any questions
By checking the box, you are confirming that you have read and understand the conditions of the program.
YesNo

NOTE:

We will require ID for proof of residency. APPLICANT MUST BE A PERRY COUNTY RESIDENT.
YesNo
Valid Driver's License*

Proof of Residency
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MaleFemale
Unfortunately, you do not qualify for this program.
How will getting a vehicle improve your quality of life?*

Referral Information
Name of referring organization:*
Website: *
Example: www.example.gov
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of staff person making referral: *

First NameLast Name
Job Title:*
Example: Case Manager
Official Email Address:*
Generic emails like Gmail/Yahoo will not be accepted
Work Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate why you believe this is a deserving applicant.*

Employed receiving a paystub and/or other document showing monthly income informationNot employed and/or you do not receive paystubs or income statements
Upload paystub or income information for one (1) month*

Example: Social Security determination letter
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Upload most recent bank statement or other financial e-statement*

Example: Chime, CashApp, Venmo, etc.
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Disclaimer, Consent, & Authorization
I understand that my application is not a guarantee of a vehicle.I understand that Join Hands Ministry is not involved in the distribution of vehicles and is only a referring organization.I understand that my personal information will be shared with Wheels for Women.I understand that the information I provided may be verified by Join Hands Ministry contacting the referring organization and any other organizations that I have listed in this application.I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge.I understand that providing false or misleading information may result in disqualification for receiving services or penalties as determined by the applicable policies or regulations.
Should be Empty:

Application for Referral

NOTE:

Referral Information

Applicant Information

How long have you lived at your current address?

How long have you been employed at your current job? Number (#) *

Disclaimer, Consent, & Authorization

Application for Referral

NOTE:

Referral Information

Applicant Information

How long have you lived at your current address?

How long have you been employed at your current job? Number (#) Please Select Years Months Days *

Disclaimer, Consent, & Authorization

How long have you been employed at your current job? Number (#) *