Wheels to Work. Application Information

Transcription

1 Wheels to Work Application Information Thank you for your continued support of the Wheels to Work Program. Goodwill Industries of Central NC are a non-profit organization that depends on vehicle donations from the general public, municipalities and other organizations. To provide reliable vehicles to individuals that currently do not have reliable transportation to maintain a working status. Individuals that are interested in participating in the Wheels to Work Program will be required to complete an application for processing. To obtain an application, please visit us online at triadgoodwill.org or pick up one at the corporate office located at: Goodwill Industries of CNC, 1235 S Eugene Street, Greensboro, NC or call ext Who can apply for the program? You can apply if: a. You are gainfully employed for 6 months or more (with the same employer) b. You do not currently have a vehicle titled in your name c. You can provide proof of income (last year s income tax, current pay stubs) d. You can Pass a Criminal Background, MVR & DMV check (no pending charges, fees or fines owed to DMV) e. You have a current driver s license for the State of North Carolina f. You can obtain a Car Insurance Quote, Pay for Tags/Title Transfer g. You can submit with your application $500 ~ Processing Fee (which covers, MVR, Criminal Background Check, Notary and other administrative fees, is refunded minus the mvr, criminal check and processing fee (-$50) if you decide later not to participate or infractions eliminate you from the program) h. You can provide verification of residence (same address on State ID, lease agreement, landlord information, telephone numbers) i. You can provide current utility bills in your name j. You are responsible and can maintain the upkeep on the vehicle (confirmed by Consumer Credit Counseling Service, call for an appointment) Assessment will ensure that the participant can afford the estimated upkeep and maintenance of a vehicle: $200 - $600 per month on fuel, maintenance, repairs and ongoing insurance coverage. After 90 days of your vehicle purchase and annually thereafter, you will receive a bill from the county for property tax based on the market value of the vehicle (your property tax will vary based on the make, year and model of your vehicle, estimating at around $50 80 annually).

2 Submitting a Completed Application: All participants are required to submit a completed application within 30 days of receipt of the application package. When Approved for the Program a Representative will Contact you. Then The applicant must submit a money order or cashier s check in the amount of $ (a payment arrangement can be established) made payable to: Goodwill Industries of CNC c/o Wheels to Work Program 1235 S Eugene Street Greensboro, NC Have completed the Consumer Credit Counseling Session and Received a Report. Attach all necessary documentation supporting your application: Lease Agreement, Utility Bill, Current Pay Stubs, Copy of Valid Driver s License, Social Security Card and Birth Certificate of all individuals on Lease, Consumer Credit Report, Last Year s Tax Return and other information as needed. Submit final paper work & monies within 30 days of receipt of an approved application. A representative with the Wheels to Work will contact you to inform you of your application status. Participants names may be placed on a waiting list based upon vehicle availability. PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete this form or provide misrepresentation or omission of facts, or falsification of any information represents grounds for elimination from consideration for the Wheels to Work Program if discovered early/later. I authorize The Wheels to Work Program to investigate, without liability, all statements contained in this application and supporting materials. I authorize references of former employers, without liability, to make full response to any inquiries in connection with this application to participate in The Wheels to Work Program. I agree to submit to a criminal and credit background investigation, and/or screening for illegal substances upon conditional awarding of a vehicle. I understand that this document is NOT a binding contract and under no circumstances if tendered, does NOT constitute a contract of guarantee that I will be awarded a vehicle. I understand that staff employees of Goodwill Industries will select individuals based on a need assessment. If selected as a participant, I will be required to furnish proof of all documentations for eligibility. Applicant Signature Date of Application

3 Wheels To Work Program Applicant Information Full Name: Last First M.I. Street Address Apartment/Unit # City State ZIP Code Home Phone: ( ) Mobile Phone: _( ) Voluntary Information This information is being requested in accordance with federal regulations. The information is voluntary and will not be reported to any other partnering agencies. Racial or Ethnic Group Gender American Indian/Alaskan Asian/Pacific Islander Black/African American Hispanic/Latino/Mexican White/Caucasian Other: Female Male How did you hear about this program? Newspaper/Flyer Company Employee Professional Publication Job Fair Placement Office Web Site Other

4 Wheels to Work Program Application Serving 5 Counties: Guilford, Rockingham, Alamance/Caswell, Asheboro & Randolph Corporate Office: Goodwill Industries of Central North Carolina 1235 South Eugene Street Greensboro, NC Please take the time to completely fill out this application. Date of Application: County: Applicant Household Information Status: [ ] Single (living alone) [ ] Married Gender: [ ] Female [ ] Male [ ] Single (living w/someone) [ ] Divorced [ ] Separated [ ] Widowed Applicant Name: Social Security Number: Date of Birth: Drivers License Number: State Issued In: Expiration Date: Spouses Name (if applicable) Social Security Number: Date of Birth: Drivers License Number: State Issued In: Expiration Date: Mailing City: Zip: Home/Cell Phone: Work Phone: Housing Status: [ ] Rent [ ] Own [ ] Other Monthly Rent/Mortgage: $ Length of Time Living there: Years Months

5 List the names, ages and relationship (son, daughter, niece, nephew, etc) of all persons living in your home (do not include those listed above): Name Age Relationship Licensed Driver (Yes or No) If yes, License Number & State Income Information List all sources of income for all persons living in your home. Income includes: Gross Wages (before taxes), salaries, commissions, net income from self employment (after expenses, Social Security, SSI, Alimony, Child Support, Pensions, ect. Name of Household Member Receiving Income Name of Employer or List Income Source and Type Monthly Amount Month/Year Income Began $ / $ / $ / $ / $ / Does your household receive assistance from any of the following programs? (check all that apply) [ ] Food Stamps [ ] Subsidized Housing [ ] County Day Care Subsidy [ ] Other (please list):

6 Vehicle/Transportation Information (applicant only) Do you currently own or drive a vehicle: [ ] Yes (if yes, see below) [ ] No Vehicle Year: Vehicle Make: Vehicle Model: Miles on Vehicle: Estimated Vehicle Value: Registered in your name? Loan Obligation on Vehicle? Unpaid Loan Amount: Loan Payable to: Vehicle Insures: Insurance Company: Coverage & Monthly Cost: [ ] Yes [ ] No /$ License Plate Number: License Expiration Date: Licensing State: If vehicle is not registered in your name list registrant name: If you do not currently own a vehicle, indicate method of transportation to and from work, school and appointments: Driving History (applicant only) DUI, OWI, or Alcohol related citations in past 5 years: [ ] NO [ ] YES Can you drive a vehicle with manual (Standard, or Stick/Shift) transmission? [ ] NO [ ] YES Has your driver s license ever been suspended or revoked: [ ] NO [ ] YES Other criminal/civil convictions in past 5 years: [ ] NO [ ] YES, please explain Do you have a driver s license: [ ] NO [ ] YES Did you ever own or had a vehicle titled in your name? [ ] NO [ ] YES Has your insurance company ever canceled your insurance: [ ] NO [ ] YES Please rank, using 1 as being most important and 7 as being least important, the value to you of the following vehicle uses: Education Recreation Shopping Vacations Joy Ride Employment Medical Appointments/Needs Visiting Relative/Friends Other

7 Employment History (Applicant, list your last two Employers list most recent first) Employer Name: Start Date: End Date: Employer City/State/Zip: # of miles from home to work Job Title: Hourly Wage/Salary: Hours Worked per Week: Supervisor Name & Telephone Number: Reason for Leaving: Employer Name: Start Date: End Date: Employer City/State/Zip: # of miles from home to work Job Title: Hourly Wage/Salary: Hours Worked per Week: Supervisor Name & Telephone Number: Reason for Leaving: Employer Name: Start Date: End Date: Employer City/State/Zip: # of miles from home to work Job Title: Hourly Wage/Salary: Hours Worked per Week: Supervisor Name & Telephone Number: Reason for Leaving:

8 References (May be contacted to provide information if/when necessary Only one relative may be included as a reference.) Name: Relationship to Applicant: Name: Home/Cell Phone: Relationship to Applicant: Name: Home/Cell Phone: Relationship to Applicant: Name: Home/Cell Phone: Relationship to Applicant: Home/Cell Phone: Are you a U. S. Citizen or Legal Alien? YES NO I/we certify that all information contained in this application is true and complete to the best of my/our knowledge and belief. Signature of Applicant Date

9 INSURANCE INFORMATION PLEASE ATTACH AN INSURANCE QUOTE General Information Name Address City/State/Zip Telephone Home Other Emergency Information Notify/Relationship Address City/State/Zip Telephone Work Other Notify/Relationship Address City/State/Zip Telephone Work Other Automobile Insurance Co Policy # Agent Phone Drivers License # Exp. Date Plate # Exp. Date Make Year Body Style # of Doors VIN Number Color

10 Wheels to Work Release Form for Media Recording I, the undersigned, do hereby consent and agree that Goodwill Industries of Central N.C., its employees, or agents have the right to take photographs, videotape, or digital recordings of me and to use these in any and all media, now or hereafter known, and exclusively for the purpose of promotional publicity for The Wheels To Work/Goodwill Industries of Central N.C. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to The Wheels To Work/Goodwill Industries of Central N.C., its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement. Please Print: Name: Date: Phone: Witness for the undersigned: Applicant Signature: Date: Wheels to Work Agent: Date: