Fill and Sign the Application Agreement Form

Carpool Application and Agreement – Ride Sharing Whereas, Carpoolers help the community by reducing air pollution and traffic congestion; and Whereas Employer supports carpooling by allocating preferred parking slots to carpoolers and by helping employees to locate neighbors interested in sharing rides; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Ridesharer agrees as follows: Ridesharer understands and agrees to receive the names of potential ridesharers, and agrees to promptly complete and sign this application and forward it to Human Resources. I understand and agree that if I drop out of the carpool, I am to notify the Rideshare Coordinator. Ridesharer represents that the following information is true and accurate. Name of Ridesharer _______________________________________________ Home Address: _________________________________________________________ __________________ (street address, city, state, zip code) Home Telephone ________________ Work Telephone ________________ My work location is (describe where it is) ____________________________________ ______________________________________________________________________ My normal work hours are from _________ A.M. to ________ P.M. I current commute to work by: [ ] Drive alone [ ] Public transportation [ ] Walk or bike [ ] Carpool with _____ (number) others [ ] Other ____________ How many miles do you travel to get to work? ____________ miles How many days a week would you prefer to carpool? ____________ days Do you prefer to: [ ] Drive [ ] Be a passenger [ ] Share driving Do you have the use of a car in good repair that is properly registered and insured? [ ] Yes, for ____________ days a week. [ ] No Do you have a current, valid drivers license? [ ] Yes [ ] No What share of the driving are you willing to do? [ ] My fair share but no more [ ] My fair share plus a bit [ ] All the driving [ ] Cannot or will not drive How far from your home would you travel to pick up other carpoolers? [ ] 0 miles [ ] 1 mile [ ] 5 miles [ ] ____________ miles Would you join a nonsmoking carpool? [ ] If possible [ ] If necessary [ ] No Would you join a smoking carpool? [ ] If possible [ ] If necessary [ ] No The Rideshare Coordinator has my permission to release this information to other employees interested in ridesharing. I understand and agree that our Employer is merely helping employees find potential ridesharers and that it is my responsibility, not theirs, to determine whether a prospective carpooler is licensed and capable. To this end, I agree that I will show my fellow carpoolers my drivers license, disclose any tickets I have received, give my registration, and my insurance company and number.. WITNESS my signature as of the ____day of _________________, 20_____. _________________________ (P rinted Name) _________________________ (Signature of Carpooler)