Please submit your information to enroll in our FREE ridematch program and remember to submit the name of the person that referred you at the bottom. Please contact us at 1.866.569.7433 if you have additional questions.

Fields marked (*) are required

Applicant Information:

* First Name:

* Last Name:

Middle Initial:

* Home Street Address:

Apt #

Bldg #

* City:

* State:

* Zip Code:

* Contact Phone:

Sex ( M/ F):

* Email Address:

Company Information:

* Company Name:

* Company Street Address:

Suite #

* City:

* State:

* Zip Code:

Department:

Work Hours:

* Start Time:  AM PM

* End Time:  AM PM

Days that you work: (check all that apply)

 Mon Tues Wed Thurs Fri Sat Sun

Can you arrive and/or leave work within 15, 30 or 45 minutes of your scheduled time?

 Yes No

If you answered YES to the above question, check one of the following:

 15 30 45

Commuting Information:

Mark the NUMBER of days per week you use each of the following methods of transportation to get to work:

Drive Alone:

Carpool: / with how many other people?

Vanpool: / with how many other people?

Bus:

Train:

Walk:

Bike:

Telework:

How long have you used your current method of commuting?

Years: Months:

Additional Information:

Please tell us how you heard about Commuter Services? For example, from your employer, a friend, a billboard or some other way.

*Who referred you?

 I agree that my information will be entered into Commuter Services' Commuter Database and used for enrollment in their Rideshare program, and that my information will not be provided by Commuter Services to outside marketing agencies. I acknowledge that participation in a carpool or vanpool or the use of other commuting options is an individual decision and that I am responsible for my operation or participation in a carpool or vanpool. Susquehanna Regional Transportation Partnership (SRTP), its contractors, or Commuter Services shall have no responsibility or liability for any claims, expenses or damages resulting from any individual's participation in a carpool or vanpool or use of other commuting options. I acknowledge that it is my responsibility for determining, from any commuter or vendor names provided, the suitability of others to be in a carpool/vanpool/ERH ride with me, including but not limited to background, driving history, and roadworthiness of vehicles. I may choose to be removed from the Commuter Services Commuter Database at any time upon my request. I understand I must be at least 18 years old to participate in this program.

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