Tampa Bay Non-Profit Transportation Service

Client Referral APPLICATION by Employer

(fields in red are required)

Name of Referral Employer:
Phone Number:
Email:

Name of Supervisor:
Title:
Phone Number:
Email:

Please provide employment information about the employee you are referring.
Job Title:
Salary (per hour):
Hours worked per week:
When did you start?
Responsibilities:
Additional statement regarding reliability and commitment to work:

Name of Client:
Spouse/Significant Other:
Child's Name & Age:
Child's Name & Age:
Child's Name & Age:
Child's Name & Age:
Address:
City:
State:
ZIP:
Phone Number:
Alternate Number:
Email:
Date of Birth (for AAA purposes)
Have you ever been involved in a domestic violence situation?
Ethnic background (optional, for statistical purposes)

Emergency Contact:
Name:
Relation:
Phone Number:

Do you currently own a vehicle?
If YES, is it operable?
What is the condition?
Year / Make / Model:

Do you have a valid driver's license?
Driver's license number:

Do you have auto insurance?
Insurance Company:
Policy Number:
Agency Name:
Agency Phone Number:

Can you drive a stick?

Client should provide a personal statement describing the current personal circumstances and how s/he believes that assistance from Wheels of Success can affect his/her family members’ lives.
How did you hear about Wheels of Success?
By submitting this application for assistance, you give Wheels of Success, Inc. permission to contact your employer, review your drivers license and vehicle insurance.

Wheels of Success is Tampa Bay's only 501(c)3 nonprofit organization providing a full range of transportation solutions, including vehicle replacement; car repair; and licensing, car payment and down payment assistance to low and moderate income working families.

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