How many people will be participating in your carpool?

Final Work / Carpool Location:

Carpool Origin (ZIP code)

Does your carpool have a vacant seat?

Yes

No

Would you be willing to take additional carpoolers?

Yes

No

Applicant Information (Please fill in ALL yellow items)

PREFERENTIAL CARPOOL PARKING REGISTRATION

Participants: (One participant is mandatory, other than yourself)

Vehicle Model:

Driver License #:

Vehicle Make:

Vehicle Plate:

Vehicle Information

Address:

Location/Building:

Agency/Dept:

Employee ID #:

Name:

County Email:

Address:

Location/Building:

Agency/Dept:

Name:

Employee ID #:

County Phone #:

Address:

Location/Building:

Agency/Dept:

Name:

Employee ID #:

County Phone #:

Address:

Location/Building:

Agency/Dept:

Name:

Employee ID #

(Non-County employees use last four numbers of SSN)

County Phone #:

By submitting this form I acknowledge that I have read the preferential carpool parking policy listed in the County of Ventura
Administrative Manual.

By submitting this form I agree to all rules and guidelines pertaining to the use of preferential carpool parking. This includes but is not
limited to proper permit placement on the vehicle, and proper use of preferential carpool spaces. I understand that participating in
this program does not guarantee a parking space.

Carpool Information

Confirmation of Carpool Program Outlines

Form Name/folder

Address:

Location/Building:

Agency/Dept:

Name:

Employee ID #:

County Phone #:

GSACPPA (Rev. 7/1/2011)

Submission Date: