EOPS Gas Card Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

PLEASE NOTE: Funding for transportation is limited, and gas cards will be distributed each time on a first-come-first-serve basis.

First Name *

Last Name *

Student ID # *

Address *

City *

State *

Zipcode *

Telephone # *

Message # *

Are you... *

please check ONLY one

EOP&S

CARE

Required

Are you... *

please check ONLY one

New

Returning

Continuing

Required

I certify that if I receive transportation assistance in the form of gas card from the EOPS/CARE Program that it will be used for providing transportation to and from school and/or to my child care provider. Also, I understand that I must be enrolled in at least 9 units (EOPS Regulation) in order to be eligible for a gas card. I further understand that the gas card is not meant to be given, sold, loaned or transferred to others. Moreover I understand that the gas card will not be replaced if lost, stolen, damaged, or destroyed. Additionally, I understand that I will not be eligible to receive this assistance if I fail to stay in compliance with the EOPS/CARE Mutual Responsibility Contract. Moreover, I understand that if I begin the semester receiving gas cards, I am not eligible to also receive bus tokens during the same semester. I have read, understand, and agree. *

Note: Typing full name will be used as a substition for your signature

Today's date *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms