Apply to Barriers to Work Program Before applying for a low-cost vehicle, please make sure that you have reviewed and met the Barriers to Work Qualifications Review Qualifications Today's Date * MM DD YYYY Name * First Name Last Name Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email Marital Status * Married Separated Divorced Single Widowed Cohabitating Are you actively involved in church? * Yes No If so, where? Are you currently employed 30 hours a week or more? * Yes No Who is your employer? Employer's Phone Number (###) ### #### Do you have a valid driver's license? * Yes No Spouse's Information Spouse's Name First Name Last Name Phone (###) ### #### Employer Employer's phone number (###) ### #### If spouse is currently unemployed, please give a detailed explanation as to why? Household Information Do you have children living in the home? * Age 17 and below Yes No If yes, please all names, ages, and relationship of child Please list the names, ages, and relationship of anyone in the home over the age of 17. How many of the individuals listed own a vehicle - running or not running? * What is the estimated yearly gross income for EVERYONE in the household? * $ Do you have any outstanding debts or loans? * Yes No If you answered yes to the above question, please describe below. ASIDE from regular medical appointments, grocery shopping, or any other normal day to day activities, describe how receiving a low cost vehicle would impact your life and/or your family's lives? * Why do you feel that you should be selected to receive a low-cost vehicle above all others applying? * This question can be the determining factor for being selected. The more effort and detail that you provide, the greater the possibilities are for being selected. How long have you been without a vehicle? * What do you believe to be the cause of this? * What is your current method of transportation? * List two references, NOT related to you with their working phone number and your affiliation. * Have you prepared a detailed budget showing that you are able to cover the cost of the vehicle as described above? * Yes No Are you prepared to attend all required courses in order to qualify? * Yes No Have you read the above requirements, are you able to fulfill them and provide verification? * Yes No Please ensure that your application is accurate AND complete before submitting. If your application is incomplete, it will not be processed! Thank you!
