511 Contra Costa Vanpool Passenger Application Form
Please complete this form within the first three (3) months of joining your vanpool. Applications received after you have been a member of your vanpool for three (3) months may not be considered for this program. The vanpool must be registered with the Countywide Vanpool Incentive Program in order for you to qualify for the vanpool passenger incentive.
First Name *
Your answer
Last Name *
Your answer
Home Address *
Your answer
Apt. No.
Your answer
Home City *
Your answer
Home Zip *
Your answer
Phone *
xxx-xxx-xxxx
Your answer
Email *
This will be used to process your vanpool reimbursement
Your answer
Name Of Employer *
Your answer
Address of Employer (worksite location) *
Your answer
Employer Suite No.
Your answer
Employer City *
Your answer
Employer Zip *
Your answer
Work Phone *
xxx-xxx-xxxx
Your answer
When did you join the vanpool? *
MM
/
DD
/
YYYY
What do you estimate your monthly vanpool fees will be? *
Your answer
Are you joining a new or existing vanpool? *
Required
Will you be a driver, passenger, or both? *
How did you get to work before you joined a vanpool? *
What is the name of the vanpool driver or coordinator? *
Your answer
What is the email or phone number of the vanpool driver or coordinator? *
Your answer
Please read the fine print and click the box indicating you have done so. *
I hereby declare the information I provided is true to the best of my knowledge and understand that falsifying information can resulting disqualification from the “Countywide Vanpool Incentive Program”. I also understand that any funds I receive are fully taxable under Federal Law. COUNTYWIDE VANPOOL RELEASE AND WAIVER OF LIABILITY I, the undersigned, recognize that participation in the Countywide Vanpool Incentive Program is strictly voluntary and that such participation is not within the course and scope of my employment. I, the undersigned, request to register my participation in the Countywide Vanpool Incentive Program. I hereby assume full responsibility for all risk of injury or loss, including death, which may result from my participation in this program. I agree to hold harmless,release, waive, forever discharge, and covenant not to bring suitor claim against the City of San Ramon/SWAT or the Company, or their respective officers, agents, and/or employees from any and all claims and demands which the undersigned may have against the City of San Ramon/SWAT or the Company, or their officers, agents and/or employees, by reason of an accident, illness,injury, or death or damage to or loss of destruction of any property arising or resulting directly from my participation in the Countywide Vanpool Incentive Program and occurring during such participation,or any time subsequent thereto, whether or not such loss,injury, or death is caused or alleged to be caused in whole or in part by the negligent acts or omissions of the City of San Ramon/SWAT, the Company, or their officers, agents, or employees. The terms of this release is binding on my heirs, executors,administrators, and for all my family members as well as myself.
Required
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How did you hear about this Program? *
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