Middle Peninsula Rideshare -- Application

Personal Information:

First name

*

Last name

*

E-mail

Mailing Address

*

Physical Address

* (If different)

City

*

State

VIRGINIA

Zip Code

*

Title

Organization

Work Address

*

Work Address (cont.)

City

State

Zip Code

*

Home Phone

Daytime phone

* (no dashes)

FAX

Other Information:

Gender

Smoker

Closest Intersection to your home:

*

Closest Park & Ride Lot:

Closest Intersection to your work:

* (If outside major metropolitan area)

Route Currently Taken:

Start Work

*

Stop Work

*

Check One:

Fixed Monday-Friday Schedule
Variable Schedule (please explain in comments box)

Are you willing to vary the above times by 30 min?

Yes No

Preferences:

(Please note: the fewer preferences, the higher likelihood of achieving a carpool/vanpool match)

Car available for pooling
Ride only
Send Vanpool Information
Van rider only
Smokers only
Nonsmokers only
Females only
Males only

How do you get to work now?

How did you hear of our program?

How did you prefer to be contacted?

Comments?

Please Complete before Submission