Prtc Online Application Form PDF Details

Are you looking for an easy way to apply for Public Relations Executives? If so, the PRTC Online Application Form is a great solution. This helpful guide will walk you through the entire process of applying online and provide an overview of what information is needed in order to complete your application. Whether it's just starting out or renewing a current position as a public relations executive, having access to this online form can save time, effort and have you on your way faster than ever before! Read on to learn more about the benefits of using this PRTC Online Application Form and how it can help make securing your dream job easier.

Form NamePrtc Online Application Form
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
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Form Preview Example

Sponsored by PRTC through support from the

A non-emergency medical transportation assistance program

PART I to be completed by all applicants.

PART II to be completed and signed by a medical certifier, if applying on the basis of a disability.

Completed form should be mailed to the Potomac and Rappahannock Transportation Commission (PRTC), faxed to (703) 583-1702 or converted to an electronic file and e-mailed to

Incomplete forms may cause processing delays.




City___________________________________ Zip Code: (please circle)

Proof of residence must accompany this application. Please refer to page 3 for acceptable documents.

20112 22025 22026

22125 22134 22172

22191 22192 22193

Telephone: Day (_____)_______________________ Evening (_____)_______________________

Male __________ Female __________

Date of Birth_______________________________

Social Security number (last four numbers only): XXX-XX-__ __ __ __

Why I Believe I Qualify for the Wheels-to-Wellness Program:

[] I am NOT eligible for non-emergency Medicaid transportation through the Virginia Department of Medical Assistance Services, and;

[] I am 80 years or older. (Attach a photocopy of a government-issued photo ID showing date of birth)

[] I have a disability as defined by the Americans with Disabilities Act. (Must have a certifier complete Part II)

[] I live in a low income household.

Combined household income: $_______________ Number of persons in the household: ___________

(Combined household income of not more than 1.9 times the federal poverty level. See page 3 for information.)

Transportation Accommodations I Require:






Walker [ ] Service Animal (If other than dog, specify_________________)






Other, please explain:______________________________________________

I, ________________________________ (print) _________________________________ (signature), do certify that the

information provided herein is true and accurate to the best of my knowledge. I understand my application and eligibility criteria are subject to review and verification, and misrepresentation of any information may result in suspension or termination of my program enrollment and transportation assistance. I also understand that I may be required to reimburse PRTC for any monies afforded me as a result of providing inaccurate information or misuse of the electronic purchasing card issued to me under the program rules. I understand PRTC may conduct random and periodic income eligibility checks of participants enrolled in Wheels-to-Wellness based on household income. In the event I am required to verify my household income, I will provide substantiated and valid documentation to support the information provided on this application. I understand PRTC may contact me to ask if the service being provided through the program is satisfactory. I understand that the program is funded through a one-year grant provided by the Potomac Health Foundation.

Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703) 730-(6664)

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Part II

To be completed by a physician or any one of the following state or nationally certified professionals: Physical Therapist, Occupational Therapist, Rehabilitation Counselor, Registered Nurse, or Social Worker.

Eligibility Criteria: Please check the eligibility criterion that pertains to the applicant.

[] Is required to use a wheelchair

[] Has an impairment that prohibits standing alone for ten (10) minutes or more and requires the use of a crutch, cane, brace, walker, or other assistance.

[] Cannot climb a flight of three (3) steps with an eight (8) inch rise, and cannot walk one hundred yards on a level surface of grade without pause.

[] Is legally blind . The definition of legal blindness is “central visual acuity of 20/200 or less in both eyes with best correction or visual field restriction of 20 degrees or less.

[] Has a diagnosis of a developmental or an intellectual disability, head injury, Alzheimer’s Disease or a related disorder, and has a cognitive impairment (inability to follow verbal, written, or pictorial directions) which causes disorientation, confusion, or demonstrates problematic stimulation when in an environment associated with crowds and / or noise.

[] Deaf or hearing impaired. (This guideline must be certified by either a licensed audiologist or a licensed otolaryngologist who is relying upon an audiogram for diagnosis): An individual whose hearing loss is 70 dba or greater in the 500, 1000, 2000 KHz ranges in both ears, regardless of the use of hearing aids.

Is the disability permanent? _____ Is the disability temporary? ______

If temporary, for how long (in months)? ________________________________

Do any of the following pertain to the applicant?






Has a medical condition that prevents him/her from using a seat belt.




Must travel with an escort or companion.




(If “Yes”, applicant will be required to travel with an escort at all times.)




Requires the assistance of a service animal in order to travel.



This information reflects my professional judgment that the applicant is eligible according to the criteria

established here.


Certifier’s Name:






Telephone Number:

___________________ Registry/State Certification Number: ______________________

Certifier’s Signature:

__________________________________________________ Date:_________________

To be completed by PRTC

Authorized by:___________________________________________________ Date: ____________________

Wheels-to-Wellness ID Number: ________________ Purchasing Card number:_________________________

Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703) 730-(6664)

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Sponsored by PRTC through support from the

A non-emergency medical transportation assistance program

Proof of Residency:

To provide proof of residency, the document must show your name and address of your current residence as it appears on this application. You must give a street address. A post office box or business address is not acceptable.

Homeless individuals may be able to substitute proof of residency for proof of services received if they are receiving assistance from a social service agency or a non-profit organization at a facility in one of the zip codes on page 1.

Examples of acceptable documents are:

Utility bill, not more than two months old, issued to applicant (examples include gas, electric, sewer, water, cable or phone bill). Cellular phone and pager bills are not accepted

Payroll check stub issued by an employer within the last two months

U.S. Internal Revenue Service tax reporting W-2 form or 1099 form (not more than 18 months old)

U.S. or Virginia income tax return from the previous year

Original monthly bank statement not more than two months old issued by a bank

Annual Social Security Statement for the current or preceding calendar year

Current automobile or life insurance bill (cards or policies are not accepted)

Certified copy of school records/transcript from a school in which applicant is currently enrolled, issued by a school accredited by a U.S. state, jurisdiction or territory OR a Virginia Department of Education state, jurisdiction or territory OR a Virginia Department of Education Certificate of Enrollment form (a report card is not accepted)

Virginia Voter Registration Card

Virginia driver’s license, learner’s permit or DMV photo ID card displaying the applicant’s current Virginia address

Certificate of Enrollment form (a report card is not accepted)

Current homeowners insurance policy or bill

Cancelled check (not more than two months old) with both name and address imprinted

Deed, mortgage, monthly mortgage statement or residential rental/lease agreement

U.S. Postal Service change of address confirmation form or postmarked U.S. mail with forwarding address label

Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703) 730-(6664)

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A non-emergency medical transportation assistance program

The Federal Poverty Guidelines

How the Census Bureau Measures Poverty

Sponsored by PRTC through support from the

Following the Office of Management and Budget's (OMB) Statistical Policy Directive 14, the Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty. If a family's total income is less than the family's threshold, then that family and every individual in it is considered in poverty. The official poverty thresholds do not vary geographically, but they are updated for inflation using Consumer Price Index (CPI-U). The official poverty definition uses money income before taxes and does not include capital gains or noncash benefits (such as public housing, Medicaid, and food stamps).

Source: U. S. Census Bureau, Small Area Income & Poverty Estimates for states and counties; updated every year. .

The Definition of Household Income

Household income is the sum of money income received in the calendar year by all household members 15 years old and over, including household members not related to the householder, people living alone, and other nonfamily household members. Included in the total are amounts reported separately for wage or salary income; net self-employment income; interest, dividends, or net rental or royalty income or income from estates and trusts; Social Security or Railroad Retirement income; Supplemental Security Income (SSI); public assistance or welfare payments; retirement, survivor, or disability pensions; and all other income.

The household income limits appearing in the table below are 1.9 times the 2014 Census Bureau definitions of poverty. The limits shown in the table are the limits that will be used to qualify residents for the Wheels-to-Wellness program on the basis of low income households.


Persons in family/household

Income guideline



For families/households with more than 8 persons, add $7,714 for each additional person.






























Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703) 730-(6664)

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