International Students Naval Postgraduate School Bus Program Application Form
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1INTERNATIONAL STUDENTS
NAVAL POSTGRADUATE SCHOOL BUS PROGRAM APPLICATION
Select Application Type:
Enrolling
Making a Change
Withdraw
Effective Date: __________
1. Applicant Information:
Country of Origin: _________________________
Last Name: _______________________________ First Name: _______________________________ MI: ___
Address: ________________________________ City/State: ________________________ Zip Code: ______
Email: ________________________________ Home or Cell Phone No.: _______________________________
2. Employee Certification of Actual Costs:
Monthly Commuting Cost: ___________
* In order to ensure you receive the appropriated monthly pass, you must commute to and from
work/school more than three times per week.
I certify that I will commute more than three roundtrips to and from work/school per week.
I certify that I am an International Student with the Naval Postgraduate School, and I am not a contractor.
I certify that this information is accurate and agree to notify the Installation POC of any change to the info provided.
I certify that the monthly transit benefit amount reported on this form does not exceed my monthly commuting costs.
I certify that I will use this benefit for my daily commute to and from work and will not transfer it to another individual.
I agree to notify the Installation POC should the fare amount and/or my ridership level increase/decrease.
I certify that upon transfer, separation, termination of employment or retirement/resignation, I will return any unused vouchers
or outstanding debt to the Installation POC.
I certify that the transit benefit I am receiving meets the criteria outlined in IRC 26 Section 132(f) as well as any further
restrictions mandated by the DON.
Employee Signature:
___________________________________
Date: _____________
_____________________________________________________________________________________________
3. Reviewing Official Acknowledgement of the International Program Office:
I certify that the applicant is authorized to participant in the Bus Program.
Reviewing Official Signature: _____________________________
Date: ______________
IPO Instructions to POC:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. Certifying Program POC for distribution:
Certifying Official Signature: _____________________________
Date: ______________
POC Notes:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Effective December 7, 2010
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