Take the Wheel Can Help You Get into a Reliable Car You Can Afford Click here to learn more about the program before you apply. INTAKE INFORMATION Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone * (###) ### #### Birth Date * MM DD YYYY Why are you interested in Take the Wheel? Purchase a car Refinance your current car Unsure Do you have a car? Yes No Do you have an outstanding car loan? Yes No What is your car payment? $ What is your current car loan interest rate? Do you have car insurance? Yes No Applicant Information Applicant Race * White Black/African American American Indian/Alaskan Native Hispanic/Latino Asian Native Hawaiian/Other Pacific Islander Black/African American and White Asian and White American Indian/Alaskan Native and White Hispanic/Latino and White Hispanic/Latino and Black/African American American Indian/Alaskan Native and Black/African American Other Applican Ethnicity * Hispanic Non-Hispanic Applicant Gender (please check all that apply to you) Female Male Other Foreign Born * Yes No Veteran * Yes No Handicapped/Disabled * Yes No Active Military * Yes No Education * Below High School Diploma High School Diploma or Equivalent Two-Year College Bachelor's Degree Advanced Degree Marital Status * Single Married Divorced Separated Widowed Household Type * Female headed single parent household Male headed single parent household Single Adult Two or more unrelated adults Married with children Married without children Other Total # of Adults in Household? * Ages * Total # of Dependents in Household? * Ages * Place of Employment Position/Title Address Start Date Type of Employment Full-Time Part-Time Self-Employed How often are you paid? Weekly Bi-Weekly Semi-Monthly Monthly Annually Monthly Income Employment $ Self-Employment $ Disability and/or SSDI Income $ Alimony/Child Support $ Social Security/Pension/Retirement Income $ Food Stamps $ Other $ Other Members of the Households Monthly Income *Take the Wheel serves those with household income up to 120% of the area median income $ Funds Available to pay bills & Debts, Save & Invest Checking Account $ Saving Account $ Investment Account (Stocks, Bonds) $ Cash $ Retirement Account $ Other $ How did you hear about Take the Wheel? Radio Facebook Laconia Daily Sun - Paper Laconia Daily Sun - Online Family/Friend Other Do you have a valid NH Driver's License? Yes No Does a defaulted car loan appear on your credit report? *If yes, we are sorry but currently it will make you ineligible for the program. Yes No Unsure Thank you!
