Commuter Solutions Carpool Gas Card Reward Application
 
Please fill out completely. Fields marked with an asterisk * are required. Please allow 2-3 weeks for delivery of your Gas Card. If you are not carpooling now but intend to form a carpool you should complete the application now. You will then receive a matchlist of potential carpool partners. If you can start a carpool then complete questions 24-32 after you have been carpooling once a week for a month. You will receive your gas card within 2-3 weeks of submitting the additional information. Please save the link to this application for your later submission.
 
1. Last Name*
2. First Name*
3. Middle Initial
4. Home Street Address Number*
5. Home Street Name*
6. Home Address Line 2 or Apartment or Unit
7. Home City*
8. Zipcode*
9. Closest Intersection to your Home: Your address does not appear on matchlists. A nearby intersection is used to give potential carpool partners your general home location.
10. Mailing Address (if different from street address)
11. Home Phone: You must provide at least one means of contact - home phone, work phone, or cell phone - plus your email address.
12. Work Phone: if you can be reached at work.
13. Cell Phone: if you prefer to be contacted this way.
14. Employer [Students are not eligible for this promotion.]*
15. Work Address*
16. Building or Suite Number
17. Arrival time at work:*
18. AM or PM*
AM PM
19. Time Leaving Work*
20. AM or PM*
AM PM
21. Are your hours flexible?*
Yes No
22. Flextime at begin work time.
15 Min.
30 Min.
45 Min.
60 Min.
More than 60 Min.
23. Flextime at end work time.
15 Min.
30 Min.
45 Min.
60 Min.
More than 60 Min.
24. What is your current usual mode of transportation?*
Drive Alone
Carpool
Vanpool
Transit
Bicycle
Walk
Other
25. If other please describe:
26. Are you currently carpooling to work on a regular basis?*
Yes No
27. How many people are usually in your carpool, inluding the driver?*
1 2 3 4 5 or more
28. How many miles do you carpool from your carpool start point to work (one-way). *
29. How many days per week do you usually carpool?*
1 2 3 4 5 6 7
30. Please enter the full names of persons in your carpool who wish to qualify for the $10 gas card.
(Each person who wishes to qualify must complete this application separately).*
31. Are you willing to add more riders to your carpool?
You must agree to qualify for the gas card reward.*
Yes No
32. Where do you start your carpool?*
The driver picks up riders at their homes.
Riders drive to a park & ride location then start the carpool.
Varies, depending on who is driving.
33. If your one-way commute is more than 20 miles: would you be interested in joining or starting a vanpool route?
Yes No
34. In a carpool do you prefer to be a:*
Driver Rider Either
35. If potential carpool partners are identified, would you prefer to be contacted at: (check all that apply).*
Home Phone
Work Phone
Cell Phone
Email
36. Additional Comments to appear on your matchlist that may be helpful. (No smoking, etc.)
37. Additional Comments to Commuter Solutions staff.
38. Please enter your email address.
39. By submitting this application I agree to provide my information to possible new carpool riders. Other riders in my carpool can qualify by submitting their own application.
Please note:
Participation in a carpool or vanpool is an individual decision. Submitting your information to Commuter Solutions does not obligate you to join a carpool. Rather, it is an expression of your interest in exploring carpool options available to you.
Disclaimer:
Commuter Solutions is acting solely as a referral service for potential carpoolers, and as such, does not assume any liability nor represent that any driver is qualified, competent or insured.*
Agree Do Not Agree

 
* Indicates field is required.