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Last
Name: |
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First Name: |
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Home Address: |
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Home City, State, Zip: |
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Employer: |
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Work
Address: (Include mailzone/ mailstop if applicable) |
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Work City/State & Zip:
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Work Phone: |
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Email Address: |
(Work
email preferred in order to verify employment with a
TMA member company) |
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Commute Information |
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How do you
currently get to work: |
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How many miles
(one way) is your commute? |
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Arrival Time at Work: |
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Departure Time from Work: |
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Do you have any flexibility with
your arrival/departure times? |
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How many days a week would you like to carpool? |
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If
you were carpooling, would you prefer to? (Please check all that
apply) |
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Ride-Only*
Drive-Only
Share
the Driving |
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*If indicated RIDE-ONLY but you have a car and we
found you a match, would you be willing to drive if
your match does not have access to a car? |
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YES - Although my preference to Ride-Only, I would be willing to drive if you found me a
match who doesn't have access to a car. |
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NO - I will not consider being a driver at all. |
Write your own
Carpool Classified:
Example:
“Looking to carpool from Bristol. Currently drive Rte 116 to
Williston Rd. Work hours: varied days, 9am – 5pm.”
or
“Looking to RIDE only from Cambridge. I work M-F from 7am – 3pm,
some flexibility. Non-Smoker preferred.” |
If you are currently
carpooling, who else is in your carpool? (Please include name and
employer.)
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Referred by:
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Terms of Agreement for
Carpool Program
Please put your initials in each text box to the left below.
You will
not be able to participate if you do not read and
initial each line. |
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I
request to participate in Seaport TMA's Carpool
Program. I have read, printed out and agree to
the terms outlined in the
document titled
ASSUMPTION OF RISK, WAIVER OF
CLAIMS AND INDEMNITY AGREEMENT. |
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I
hereby release Seaport TMA from any liability, claims and demands for
personal injury, loss, theft or damages to my personal
property, loss of income, consequential damages
resulting from delays or absence of service provider,
or termination of the program. I also understand that
Seaport TMA has the right to discontinue
participant privileges at any time. |
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I
understand Seaport TMA will require me to
complete a monthly report for the Program and that I
will not receive any prizes
until the report has been received. |
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I certify that I
carpool at least two days per week. |
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Furthermore, I understand that incorrect use of this
program may result in
restriction from participating in the program. |
