Referring a client

If this referral is being made by a Wheels of Success partner, please select the agency or employer partner name from the dropdown:
Agency or Employer Partner Referring:
If not a Partner, Non-Partner Referral Source:
If Other, Please Specify:
If a non-partner Agency is making this referral, please fill out the following fields about your organization:
Agency Name:
Agency Contact, Phone and Email:	Agency Phone: Agency Contact Name: Contact Phone/Ext: Contact Email: Any Comments:
Information on Applicant's Employer:
Current Employer?	* Required
Employer Address, Phone and Email:	Address: Main Phone: Main Email: * Required
Nature of Business?	* Required
Years in Business?	* Required
Number of Employees?	* Required
Supervisor Name:	* Required
Supervisor Title:	* Required
Supervisor Phone:	* Required
Supervisor Email:	* Required
Human Resources Director Name:	* Required
HR Director Phone:	* Required
HR Director Email:	* Required
Applicant Information:
First Name of Applicant	* Required
Last Name of Applicant	* Required
Home Phone	* Required
Cell Phone	* Required
Work Phone
Address	* Required
Apartment #
City	* Required
State	* Required
Zip	* Required
County	* Required
Date of Birth	* Required
Gender	* Required
Email	* Required
How did you hear about us?	* Required
If you chose "Other" above, please specify:
# of Adults in Household	* Required
# of Children in Household	* Required
Please list the ages of all your children
Applicant Employment Information:
Job Title	* Required
Salary ($ per hour)	* Required
Number of hours worked per week (must be working full time, so hours must be 32 or greater)	* Required
Employment Start Date	* Required
Responsibilities	* Required
Is the applicant a patient caregiver in the medical field?	* Required
If so, what position?
Additional Statement regarding reliability and commitment to work	* Required
In order to be considered the applicant must have a valid Florida drivers license.
Drivers License number	* Required

Has the applicant ever been the victim of a domestic violence situation	* Required
Ethnic background (for statistical purposes)	* Required
If Other, Please Specify
Is the applicant a U.S. military veteran	* Required
Which Branch of Service?
Discharge Date?
Military Occupation / Job Type?
DD Form 214 Number?
Is applicant in foster care or considered an Unaccompanied Youth?	* Required
*Additional monthly* Income:** Please enter numbers only, and enter 0 if none or not applicable:
SSI:	* Required
Child Support:	* Required
Second Job:	* Required
Spouse / Significant Other in the household:	* Required
School Information: If applicant is attending school, all school-related fields are mandatory
Is applicant attending school?	* Required
School Name
Major area of study
How many hours per week
Expected Graduation Date
Vehicle Information: If the applicant currently owns a vehicle, all vehicle-related fields below are mandatory
Is a vehicle, repair, or other service needed?	* Required
If Service is needed please explain
Was vehicle lost in a hurricane or flood?
Which Storm?
Does the applicant currently own a vehicle?	* Required

If yes, is it operable?
What condition is it in?
Is applicant still making payments on the vehicle?
Amount owed on vehicle
Monthly payment for vehicle
Year
Make
Model
Mileage
Do you have auto insurance?	* Required
Insurance Company
Policy Number
Can the applicant drive a stick (manual)?	* Required
Personal Statement:
Applicant should provide a personal statement describing the current personal circumstances and how he/she believes that assistance from Wheels of Success can affect his/her family members lives.	* Required

Permission Statements: Both must be read and checked
By submitting this application I hereby give permission for Wheels of Success, Inc. to verify, review and discuss my driving record(s) and/or the validity of my Driver's License, as required for processing my application	* Required

By submitting this application I hereby give permission for Wheels of Success, Inc. to verify, review and discuss any information in this application with the referring agency and/or my employer in order to establish eligibility	* Required

Date of Application (Enter Today's Date)	* Required

Please leave this checkbox blank