Last
Name:
First
Name:
Home Address:
Home
City, State, Zip:
Employer:
Work Address: (Include mailzone/mailstop if applicable)
Work
City, State, Zip:
Work Phone:
Email Address:
(Work email
preferred in order to verify employment with a TMA
member company)
How many miles
(one way) is your commute?
Arrival Time at Work:
Departure Time From Work:
In most cases, where would you need to get to in
case of an emergency: (SELECT ONLY ONE
OPTION)
Home (I do not
park my vehicle at a transit station.)
Transit Station (I park my vehicle here and would
need to get to it). Please specify the
station:
Other. Please provide details:
Indicate the number of days per week you currently
travel by:
Referred by:
Terms of Agreement for
Guaranteed Home Program
Please put YOUR INITIALS in each text box to the left below.
I
request to participate in the Seaport TMA's
Guaranteed Ride Home
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 .
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.
I
understand that the Seaport TMA requires me to
complete a follow-up survey/confirmation report if I
use the Guaranteed Ride Home to ensure that my
travel needs were met. I
understand that the report must be
completed in its entirety and submitted, along with
the cab voucher receipt sent to me and/or a printed
cab receipt, within one week after each use
of the program to be eligible for another Guaranteed
Ride Home.
I understand that
if I lose my voucher, a replacement voucher will be
issued to me. I understand that each replacement
voucher counts as one of my yearly uses.
I understand that
if I give my voucher to someone else, it will count
as two of my yearly uses.
Furthermore, I understand that incorrect use of this
service may result in revocation of reimbursements and
restriction from using the service again.
