Date of Enquiry:DB:Local Authority: Project Code:

W2W staff to complete – DO NOT FILL IN THIS SECTION:

Driving licence provided/Checked: . Evidence of work/training provided: .

Initial payment received: . CBT vouchers sent: . Dealer: .

Date of CBT: . Date of CBT+: . Trainer: .

Notes:

Enquiry form for Wheels to Work Derbyshire,Nottinghamshireor County Durham

______

Please note that this is an enquiry form, you will be sent the full application pack if you’re eligible. For moped loans, we need the advance payment/deposit before you take any training. You then pay regular loan payments abiding by your loan agreement. ______

About You?
Name: ______/ Date of Birth: / Age:
Address: ______
. .
Postcode: ______/ Tel: ______/ Mobile: ______
Email: ______/ National Insurance No:______
Emergency Contact:______Relationship to you: ______
Telephone: ______/ Mobile:______

What WHEELS to WORK help is needed? (Prices per week)

50cc Moped loan (£25)☐ / 100+cc Moped Loan (£30)☐
Electric bike ☐ New Bicycle ☐ / Reconditioned Bike☐

Please tick all categories that apply to you:

Employed / ☐ / Unemployed / ☐
Claiming benefits / ☐ / In training / ☐
In education / ☐ / Previously NEET
(not in Employment or Education) / ☐
Employed in training / ☐ / In care/care leaver / ☐
Self employed / ☐ / Apprenticeship / ☐
About Your job/Course?
Employer/Company Name: ______/ Your Job/course Title : ______
Address: ______
Postcode: ______
Contact Person: ______
(Line Manager, or supervisor) / Telephone: ______

About your Workplace:

Approx. distance of commute/travel: ______Days of work: ______

Start time of work: ______End time of work: ______

  • If you are working, are you:

Changing Jobs ☐ / Returning to Work ☐ / Continuing the same job ☐

If out of work, how long have you been out of work for: ______

______

  • What public transport is available to your workplace/ place of education (Please include bus number if available)? ______
  • If your job/training has already started, how do you currently get there______
  • Have you applied to Wheels to Work before? Yes ☐No ☐
  • Where did you hear about Wheels 2 Work? ______
  • Have the Job Centre referred you as part of the ‘Work Programme’ to:

Ingeus ☐orPeople Plus ☐or Neither ☐

MOPED ONLY:

  • Why have you applied for a moped loan? ______

•Driving licence held: Full ☐ Provisional ☐ Applied for ☐ CBT taken?☐

Driver No ______Licence Expiry

Date of CBT if taken Please send a copy of your license & certificate to us.

Signature: …………………………………………….Date: ……………………………………………..

By signing this form you are giving permission for Wheels to Work to share your details with the garages/bicycle shop we work with; and our funders; and – for mopeds – to share specific data with DVLA for the purpose of checking your driving licence.

W2W Staff Please Detach:Code/Year :Transport Option:

Equal Opportunities Monitoring

This information is required by our funders to ensure we are helping as many different people as possible - it will be detached from the application therefore kept anonymous.

Please tick the boxes that apply to you:

Ethnic background:

White

  • English/Scottish/Welsh/Northern Irish/UK☐
  • Irish☐
  • Gypsy or Irish☐
  • Any other white background☐______

Asian/Asian UK

  • Indian☐
  • Pakistani☐
  • Bangladeshi☐
  • Chinese☐
  • Any other Asian background☐______

Black/African/Caribbean/Black UK

  • African☐
  • Caribbean☐
  • Other Black/African/Caribbean background☐______

Other ethnic group

  • Arab☐
  • Any other ethnic group☐ ______

Gender:male☐female☐prefer not to say☐

Age: 0-24 years☐25-39 years☐40-64 years☐65+ years☐

Do you have a disability:yes☐no☐

Sexual orientation: prefer not to say ☐ heterosexual ☐ homosexual☐ bisexual☐

(straight)(gay/lesbian)

Religion or belief:

  • No religion☐
  • Christian☐
  • Buddhist☐
  • Hindu☐
  • Jewish☐
  • Muslim☐
  • Sikh☐
  • Other religion☐______

Return this application form along with: proof of employment & a copy of your driving licence to – Notts: Derbs: N.Durham:

for postal addresses see our website or call 01629 592 976