getting around carpooling application

CARPOOL / VANPOOL APPLICATION — SOUTHERN NEW JERSEY

An asterisk ( * ) denotes a required field. Your application cannot be processed if required fields are not completed. You must work in either Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, or Salem county in New Jersey in order to apply. You can also print and mail in this application.

Name*:

First: Last:

Email Address:

Home Address*:

Street Address: Apt. # :

City: State: Zip:

Home Phone:(optional)

Employer*:

Work Address*:

Street Address:

City: State: Zip:

County:

Work Phone*:

Work Hours*:

From:

To:

Work Days*:

Mon Tues Wed Thurs Fri

Sat Sun

How many miles do you travel one-way from home to work?*

How did you hear about the Rideshare program?*

Newspaper/Magazine Which one:

Sign Event Radio Internet Friend Television

OTHER:

I currently commute*: (please check all that apply)

Driving Alone Train Carpool Bicycle
Vanpool Walking Bus # Other

Do you want your home address and phone # to appear on match lists sent to interested carpoolers?

Yes

I am a: Smoker Non-Smoker I prefer to smoke in the vehicle.

Is your vehicle available for car/vanpooling? Yes No

I am willing to carpool as a: Passenger Driver

I am willing to vanpool as a: Passenger Driver

Do you prefer to be picked up at a location other than your home? Yes No

If yes, location: