<p> WFNJ-132 (Rev. 4/03) (Page 1) WORK FIRST NEW JERSEY/NJ TRANSIT’S “GET A JOB, GET A RIDE” AND “EXTENDED WORKPASS” PROGRAMS ENROLLMENT FORM</p><p>INDIVIDUAL INFORMATION – To Be Completed By Post-WFNJ/TANF/GA employed individual. Print Clearly. All Spaces Must Be Completed or Form Will Not Be Processed. Only Original Forms with Original Signatures Will Be Accepted. NAME: ______</p><p>STREET ADDRESS: ______(Do not use a Post Office Box Number) TOWN WHERE YOU LIVE: ______(Include City, State and Zip Code) MAILING ADDRESS: ______(If Different than your Home Address) YOUR SOCIAL SECURITY NUMBER: ______</p><p>YOUR PHONE NUMBER OR A CONTACT’S TELEPHONE: ______</p><p>YOUR EMPLOYER’S NAME: ______</p><p>AND ADDRESS: ______(Include Street, City, State and Zip Code)</p><p>______ JOB INFORMATION:</p><p>STARTING DATE: ______JOB TITLE: ______</p><p>CHECK ALL: ( ) Full-Time ( ) Part-Time ( ) Working Monday-Friday Only ( ) Working Weekends THAT APPLY</p><p>SHIFT TIMES: Start Time: ______Shift Ends: ______Hours per Week: ______</p><p></p><p>I WISH TO APPLY FOR THE “GET A JOB, GET A RIDE” PROGRAM ( ) YES ( ) NO (You must check yes to receive the free one-month bus, light rail or rail pass from NJ Transit for Post WFNJ/TANF/GA employed individuals)</p><p>I WISH TO APPLY FOR THE “EXTENDED WORKPASS” PROGRAM ( ) YES ( ) NO (You must check yes to receive the free six-month bus, light rail or rail pass for post WFNJ/TANF employed individuals only)</p><p>I understand that by completing this form, I have agreed with my agency worker that I am in need of: ( ) A BUS PASS ( ) A RAIL PASS. ( ) A LIGHT RAIL PASS YOUR SIGNATURE: ______By signing this form, I agree to permit NJ TRANSIT to contact me with their follow-up survey. The information will be used by NJ TRANSIT for evaluating their programs or service.</p><p> CONFIRMATION OF CASE CLOSING: This section is to be completed by a WFNJ agency staff person. Please print clearly. Complete all lines. This enrollment form is valid only with a WFNJ agency staff worker signature authorization. This signature verifies that the individual is an employed, former WFNJ recipient and a bus, light rail or rail pass is deemed appropriate. WFNJ/GA ( ) COUNTY: ______WFNJ/TANF ( ) CASE NUMBER:______CASE CLOSING DATE:______</p><p>PRINT PARTICIPANT’S NAME: ______WFNJ AGENCY: ______TELEPHONE NUMBER: ______</p><p>WFNJ AUTHORIZED AGENT’S SIGNATURE: ______WFNJ-132 (Rev. 4/03) (Page 2) WORK FIRST NEW JERSEY/NJ TRANSIT’S “GET A JOB, GET A RIDE” and “EXTENDED WORKPASS” PROGRAMS</p><p>IMPORTANTE: ESTE ES UN AVISO IMPORTANTE. SI USTED NO ENTIENDE LA INFORMACIÓN CONTENIDA EN ESTE AVISO O NO LEE INGLES, PÓNGASE EN CONTACTO CON UN REPRESENTANTE DE LA AGENCIA DE BIENESTAR PÚBLICO DEL CONDADO O DE LA OFICINA DE CUPONES DE ALIMENTO.</p><p>CONGRATULATIONS FOR OBTAINING EMPLOYMENT. YOU MAY BE ELIGIBLE FOR UP TO SEVEN MONTHS OF FREE TRANSPORTATION!</p><p>WHAT IS NJ TRANSIT’S “GET A JOB, GET A RIDE” PROGRAM NJ TRANSIT will issue a one month FREE two-zone monthly bus pass, light rail or a station to station rail pass under the “GET A JOB, GET A RIDE” Program, to WFNJ TANF and GA participants within three months of leaving public assistance for permanent employment of at least 20 hours per week. </p><p>WHAT IS WFNJ’S EXTENDED WORKPASS PROGRAM Under the “EXTENDED WORKPASS” Program, WFNJ county agencies will issue up to six monthly bus, light rail or rail passes, to any WFNJ/TANF participant who is employed for at least 20 hours a week and leaves public assistance. The monthly bus, light rail or rail passes are FREE for six months only for WFNJ/TANF participants who close their case. </p><p>4 EASY STEPS</p><p>1. After you leave public assistance, you will receive a letter from your agency worker letting you know what services you may be eligible for. If interested, please contact your agency worker. </p><p>2. You may obtain a Work First New Jersey/NJ TRANSIT “GET A JOB, GET A RIDE” and “EXTENDED WORKPASS” Programs Enrollment Form from your WFNJ Agency representative. After you sign and complete the application, if you are eligible for one or both of the programs your WFNJ agency representative will authorize and submit your application for you.</p><p>3. If you are eligible to participate, you will receive a monthly check in the mail, paid to the order of NJ TRANSIT with your name and address below. Take this check to your nearest NJ TRANSIT ticket agent to receive your bus, light rail or rail pass. Be sure to bring a picture identification with you. The passes go on sale from the 20th of the prior month through the 5th of the month that the bus or light rail pass is valid, or through the 10th of the month for rail passes. 4. For WFNJ/TANF individuals participating in the “EXTENDED WORKPASS” PROGRAM, you will receive a monthly check in the mail for your bus, light rail or rail pass for up to six months. </p><p>ASSISTANCE IN DETERMINING ROUTES:</p><p>For help in determining what bus or train you will need to take to reach your new job site, please call the nearest NJ TRANSIT Information Center. For North Jersey areas, 1-800-772-2222 daily, between 6:00 AM until 12 Midnight. For South Jersey areas, 1-800-582-5946 daily, between 6:00 AM until 10:00 PM.</p><p>S:\working\wfnjform\WFNJ-132.doc</p>