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: NJ  Zip:
	County: Atlantic Burlington Camden Cape May Cumberland Gloucester Salem
Work Phone*:
Work Hours*:	From: AM PM	To: AM PM
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 No
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: