Wheels to Work West
Applications

Applications

If you’re looking to apply to a Wheels to Work West offer, or are a partner organisation applying on behalf of someone else, please use the below forms or get in touch.

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Bath & North East Somerset Bristol North Somerset South Gloucestershire

Bath & North East Somerset

If you are unable to get help via a partner organisation, please contact us directly.

If you're based in Bath & North East Somerset:

Paul Thompson

If you're based in Bath & North East Somerset: Email Address: [email protected]

Bristol

If you are unable to receive help via a partner organisation, please complete the form below.

Could all partner organisations please also fill in the below form when handing out bus tickets to a client or referring the client for tickets or the bike offer.

Before completing the referral form please take note of our Privacy Notice.

Are you:*
- An individual in need of sustainable travel support?
- A partner organisation of Bristol's Wheels to Work scheme?
What is the name of your organisation?*
Have you provided a short term offer of free bus travel to the recipient?*
- Yes, a First Bus mTicket for smartphone
- Yes, a multi-operator bus voucher
- No, I would like to refer the individual for a Wheels to Work offer
Are you referring a client as part of the Voi Scooter trial?
- Yes
- No
This is currently Horfield and Temple St Job Centres only
Please detail the Voi code/s given out
I would like to refer the client for:
- mTickets
- Paper bus vouchers
- £100 discount on a bike
- £80 discount on a bike service
- 1 day bike maintenance training course
Please detail the ticket type provided to the individual
- Bristol Inner Zone Daily
- Bristol/ Bath Outer Zone Daily
- Bristol Inner Zone Weekly
- Bristol/ Bath Outer Zone Weekly
Please detail the mTicket code/s provided:*

If you provided multiple mTicket codes, please separate with a space.
Please detail which voucher type you provided to the individual*
- Avon Rider
- Bristol Rider
Please detail the 4 digit code from each of the bus voucher/s provided:*

If you provided multiple bus vouchers, please separate the codes with a space.
How many tickets/vouchers did you provide in total on this occasion?*
1 weekly ticket would still just be '1'
What is the main purpose of the journey the recipient is making with this support?*
- Starting a new job
- Attending a training course
- Attending a work placement
- Attending job interviews
- Other (please specify below)
Other - please specify:
How long does the recipient require the Wheels to Work support?*

How many weeks and how many days per week?
Without travel support from Wheels to Work, the recipient would make the journey by:*
- Driving
- Getting a lift
- Bus
- Walking
- Cycling
- Train
- Other
- They would not be able to make the journey without Wheels to Work support
Which of the following best describes the recipient’s situation concerning having a driving license and access to a car?*
- They have a full driving licence for a car and current use of their own/ a shared car
- They have a full driving licence for a car and current use of or access to someone else’s car
- They have a full licence but do not own or have access to a car
- They do not have a full driving license
What type of support are you interested in?*
- First bus mTicket for smartphone
- Multi-operator bus voucher
- £100 discount on a refurbished bike
- Free bike service (up to £80)
- 1 day bike maintenance training course
Sponsor details
In order to receive Wheels to Work support, you need to evidence that you are eligible for the service. Please provide the contact details for a sponsor - either your new employer, training provider, work coach, or similar - to confirm that you are eligible for this offer.
Sponsor/ Employer full name:*
Sponsor/ Employer organisation:*
Sponsor/ Employer telephone number:*
Sponsor/ Employer email address:*
What is the main purpose of the journey you will be making with this support?*
- Starting a new job
- Attending a training course
- Attending a work placement
- Attending job interviews
- Other (please specify below)
Other - please specify:
How long do you require the Wheels to Work support?*
Without travel support from Wheels to Work, you would make the journey by:*
- Driving
- Getting a lift
- Bus
- Walking
- Cycling
- Train
- Other
- I would not be able to make the journey without Wheels to Work support
Which of the following best describes your situation concerning having a driving license and access to a car?*
- I have a full driving licence for a car and current use of my own/ a shared car
- I have a full driving licence for a car and current use of or access to someone else’s car
- I have a full licence but do not own or have access to a car
- I do not have a full driving license
About you
This section is really important as it helps us to gain a better understanding of the views of different people and how they could be impacted by any changes. This information will remain confidential and will be used for analysis purposes only. Your personal information will not be published and individuals will not be identified.

To help us to improve the service we offer now and in the future we will contact you after 13 weeks to gather additional feedback about the service you have received.
Full name:*
Date of birth*

To be eligible for the scheme you must be 16 or over
Full postcode:*

To be eligible for the scheme you need to have a postcode that falls within the Bristol City Council authority boundaries.
Telephone number:*
Email address:
Please describe your current employment status
- In permanent employment
- In temporary employment
- Completing an apprenticeship/ internship/ work placement
- In training
- Unemployed
- Other
Gender:*
- Female
- Male
- Other
- Prefer not to say
Do you consider yourself to be disabled?
- Yes
- No
- Prefer not to say
If yes - please specify:
Ethnicity:
- Arab/Arab British
- Asian/Asian British – Bangladeshi
- Asian/Asian British – Indian
- Asian/Asian British – Pakistani
- Asian/Asian British – Chinese
- Asian/Asian British – Other (please state)
- Black/African/Caribbean/Black British – African
- Black/African/Caribbean/Black British – Caribbean
- Black/African/Caribbean/Black British - Other (please state)
- Gypsy or Traveller of Irish Heritage
- Mixed/Multiple Ethnic Groups – White & Asian
- Mixed/Multiple Ethnic Groups – White & Black African
- Mixed/Multiple Ethnic Groups – White & Black Caribbean
- Mixed/Multiple Ethnic Groups – Other (please state)
- White – English/Welsh/Scottish/Northern Irish/British
- White – Irish
- White – Other (please state)
- Other ethnic group (please state)
- Prefer not to say
Other - please specify:
How did you hear about Wheels to Work?
- At one of our partner organisations, e.g. Job Centre
- Through a bike shop
- Facebook ad
- Facebook post
- Google Ad
- Back of bus advertising
- Bus stop advertising
- Word of mouth
- Other
In order to benefit from the scheme you will need to provide consent for us to process your data*
Anonymised data will be processed by the University of the West of England (UWE) to assess the success of the scheme.
- Please select here to opt in to have your personal information to be held and processed by Travelwest
Thank you for taking the time to respond to this survey.
Please press the submit button below to send us your response.

Any personal information that you have supplied will be held by Bristol City Council in accordance with the Data Protection Act. This information will only be used as part of this exercise and personal information will be used as decribed in the privacy notice.
About the recipient
Please ask the recipient to provide the following personal information. This section is really important as it helps us to gain a better understanding of the views of different people and how they could be impacted by any changes.

This information will remain confidential and will be used for analysis purposes only. The recipient's personal information will not be published and individuals will not be identified.

To help us to improve the service we offer now and in the future we will contact the recipient after 13 weeks to gather additional feedback about the service they have received.
Full name:*
Date of birth*

To be eligible for the scheme you must be 16 or over
Full postcode:*

To be eligible for the scheme you need to have a postcode that falls within the Bristol City Council authority boundaries.
Telephone number:*
Email address:
Please describe your current employment status
- In permanent employment
- In temporary employment
- Completing an apprenticeship/ internship/ work placement
- In training
- Unemployed
- Other
Gender:*
- Female
- Male
- Other
- Prefer not to say
Do you consider yourself to be disabled?
- Yes
- No
- Prefer not to say
If yes - please specify:
Ethnicity:
- Arab/Arab British
- Asian/Asian British – Bangladeshi
- Asian/Asian British – Indian
- Asian/Asian British – Pakistani
- Asian/Asian British – Chinese
- Asian/Asian British – Other (please state)
- Black/African/Caribbean/Black British – African
- Black/African/Caribbean/Black British – Caribbean
- Black/African/Caribbean/Black British - Other (please state)
- Gypsy or Traveller of Irish Heritage
- Mixed/Multiple Ethnic Groups – White & Asian
- Mixed/Multiple Ethnic Groups – White & Black African
- Mixed/Multiple Ethnic Groups – White & Black Caribbean
- Mixed/Multiple Ethnic Groups – Other (please state)
- White – English/Welsh/Scottish/Northern Irish/British
- White – Irish
- White – Other (please state)
- Other ethnic group (please state)
- Prefer not to say
Other - please specify:
In order to benefit from the scheme the recipient will need to provide consent for us to process their data*
Anonymised data will be processed by the University of the West of England (UWE) to assess the success of the scheme.
- Please select here to opt in to have your personal information to be held and processed by Travelwest
Thank you for taking the time to respond to this survey.
Please press the submit button below to send us your response.

Any personal information that you have supplied will be held by Bristol City Council in accordance with the Data Protection Act. This information will only be used as part of this exercise and personal information will be used as decribed in the privacy notice.
Comments
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