4 When you dont use transit to get to work what mode of transpo - PDF document

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 4. When you don’t use transit to get to work, what mode of transportation do you use most often? Drive myself Walk Get ride from co - worker or family Bike Other : Get ride from ride sourcing app (Uber, Lyft, Carzac, Waze carpool) All stated limitations apply. Completion of this application does not guarantee delivery/receipt of a free pass. Applicants must meet all qualifications listed above and be approved by 511 Contra Costa. Signature Date 7. Acknowledgment I read the eligibility and promotion rules listed and I verify the information submitted is correct. I agree to complete a br ief questionnaire from 511 Contra Costa following my participation in this promotion. Work Site Address (P.O. Boxes not accepted) City Zip Name 6. Employer Information Daytime Phone Work Email Mailing Address (if different than above) Mailing Zip Home Address (P.O. Boxes not accepted) Home City Home Zip First and Last Name 5. Contact Information Am I eligible to apply? You are eligible to be a par�cipant if you:  Live or work in Contra Costa County.  Are 18 years of age or older.  Would otherwise drive alone to/from work if Fair�eld and All information is required to apply for free pass. Payment for first pass will be processed upon receipt. 8. Payment Method Check payable to City of Fairfield • Fommuter Benefit Fhe

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ck • Fredit Fard (VisaCMastercard) 1. How many days a week do you plan to take the bus for work? 3. How do you plan to get to the bus stop? Drive myself Carpool Walk Get dropped off Bike Other (Specify): Credit Card Number: Exp. Date: What are the promotion rules?  hne (1) free pass per person and per household during promo�on period of November 1, 2018 to Wune 30, 2019 while funding is available.  Fair�eld and Suisun Transit must serve your home - to - work and/or work - to - home commute.  We may require veri�ca�on of the informa�on you provide.  Fair�eld and Suisun Transit and 511 Contra Costa reserve the right to make any changes to the rules or to terminate this promo�on at any �me without prior no��ca�on.  If you have par�cipated in any 511 Contra Costa incen�ve program during the promo�on period, you are not eligible for this .hDh o�er.  I agree my email will be included in the 511 Contra Costa newsle�er and agree to complete post - Return with payment to: Fairfield and Suisun Transit 2000 Cadenasso Drive Fairfield, CA 94533 2. What bus route do you plan to take? Buy One Get One Free 31 - Day Pass for SolanoExpress Green Express and Blue Outside Solano County *Proof of eligibility must be submitted for SDM Pass purchase. See 11/2018 GX $130.00 OSC Blue $114.00 Amount Enclosed: 31 - Day Pass……… GX $65.00 OSC Blue $57.00 SDM Pass*………..