The Junction TMO

Participant’s Agreement

I have read and understand the Policies and Procedures of the Emergency Ride Home service and agree to participate in the service according to these rules. As a participant, I understand that transportation will be provided by a third party and that my employer or The Junction TMO cannot be held responsible for the performance of the vendor. I assume full responsibility for any risk which may result from participating in the service.

I understand that if I use the Emergency Ride Home service, my Employee Transportation Advisor (ETA) may ask me to complete a brief follow-up survey in order to ensure that my travel needs were met and to receive a new voucher for possible future use.

Please fill in and submit the form below or you may download a printable form in pdf format that you may mail or fax:

Home Information

First Name

Last Name

Home Address

City

State

Zip

Home Phone

Work Information

Employer

Department

Work Phone

Fax:

Work Address

Mail Stop:

City

State

Zip

Supervisor's Name

RIDESHARING INFORMATION

Estimated mileage (one way) from home to work:

miles

I commute to the Lowell Junction/Ballardvale Steet area at least 2 days a week by:

	Carpool			Public Transit
	Vanpool			Private Bus
	Walk			"Call and Commute"
	Bicycle			Company Shuttle

Carpool Members

Name

Work Phone

Name

Work Phone

Name

Work Phone

Name

Work Phone

I request to participate in the Junction TMO Emergency Ride Home Program.
I have read and agree to abide by the procedures and rules of the program.

Enter initials here:

Date: