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2. Gloucester County Department Transportation Services provides transportation to vocationally related endeavors for people with disabilities. This online application is for Gloucester County residents requesting transportation related to "ongoing non-competitive employment" specifically at the Abilities Solutions or St. John of God workshops. Please be aware this transportation, if approved, is provided Monday through Friday, no weekends or holidays. 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. Please call 856-686-8355 with any questions regarding this process.

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
26. Please select location of program*

    1. Abilities Solutions
    2. St. John of God
28. 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
30. Referring Agency or Person
32. Do you currently use New Jersey Access Link Services to get to work, school, or training?*

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

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

    1. Yes, I have
    2. I have not
36. 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
38. If you answered yes to the previous question, how far could you safely travel from your home to meet a Department of Transportation Services vehicle?*
    -- Select One --No more than 1 blockWithin 1/4 of a mileSomeone can drive me to and from the pick-up point within a 1/2 mile
40. Are you willing and able to utilize public transportation?*

    1. Yes
    2. No
42. 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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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field