The Junction TMO

The Junction TMO, Inc.
Stan Franzeen, Coordinator
One Burtt Road
Andover, MA 01810

ph (978) 247-3100

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:

Emergency Ride Home
Enrollment Form

Home Information
First Name			Last Name
Home Address
City			St		Zip
Home Phone
email
Work Information
Employer
Department
Work Phone			Fax:
Work Address		--MailStop:
City			St	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:

Last update: 10/16/06
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Participant’s Agreement

Emergency Ride Home Enrollment Form

Emergency Ride Home
Enrollment Form