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2. This online application is for Gloucester County residents requesting transportation related to "ongoing competitive employment". Please be aware this transportation, if approved, is provided Monday through Friday, no weekends or holidays, and within Gloucester County's boundaries. No out of county transportation would be provided for this category. A Department of Transportation and Services staff member will reach out by telephone and/or email advising the consumer of the status of the application. The completion of this application does not guarantee approval or utilization of our services. When services cannot immediately be rendered, the consumer will be placed on a waiting list. When availability arises for you, we will contact you to verify you still desire transportation. You are invited to contact us at any time to check your status on the waiting list. If you have any questions regarding this form or any others listed please call 856-686-8355. Also, please be aware that the Pureland East-West Shuttle may satisfy your needs. For more information view the Pureland East-West Shuttle page.
4. Name of Applicant*
5. Email Address
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Emergency Phone Number
16. Emergency Contact Person*
17. Date of Birth*
    Date of Birth
18. Last 4 Digits of SS#*
20. Gender*

    1. Female
    2. Male
22. Mobility Aids*
    -- Select One --CraneCrutchesElectric WheelchairManual WheelchairMotorized ScooterWalkerNone
24. Type of Disability*

    1. Cognitive
    2. Hearing
    3. Mental
    4. Mobility
    5. Oxygen Tank
    6. Service Animal
    7. Vision
    8. None
25. Racial or Ethnic Group*
    -- Select One --American Indian / AlaskanAsian / Pacific IslanderBlack / African AmericanHispanic / LatinoWhite / Caucasian
27. Please list name of location where you will be working. Include complete address and phone number.*
29. Please select each day that you will need transportation. Be advised that transport times are for a 9 am arrival and a pickup time of 3 pm for return.*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
31. Referring Agency or Person
33. Do you currently use New Jersey Access Link Services to get to work, school, or training?*

    1. Yes
    2. No
34. If you answered No to previous question, have you ever applied for New Jersey Access Link Services?*

    1. Yes
    2. No
35. Have you ever been denied New Jersey Access Link Services?*

    1. Yes, I have
    2. I have not
37. Would you be willing and able to meet a Division of Transportation Services bus at a specified pick-up point rather than at your home?*

    1. Yes
    2. No
39. If you answered Yes to previous question, how far could you safely travel from your home to meet a Department of Transportation Services (DTS) vehicle?*
    -- Select One --No more than 1 blockWithin a 1/4 of a mileSomeone can drive me to and from the pick-up point with a 1/2 mile
41. Are you willing and able to utilize public transportation?*

    1. Yes
    2. No
43. By submitting you understand that this is only an application and does not guarantee transportation services. A Department of Transportation Services (DTS) representative should contact you in 3 to 5 business days. The completion of this application does not guarantee approval or utilization of the service. Normally, there is a waiting list for ongoing Vocational Transport. Our DTS representative that contacts you will explain in more detail. Thank you for completing the DTS questionnaire.
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field