Carpool Certification - Oregon Department Of Administrative Services
Download a blank fillable Carpool Certification - Oregon Department Of Administrative Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Carpool Certification - Oregon Department Of Administrative Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Fleet & Parking Services
1100 Airport Rd SE
Salem, OR 97301-6082
CARPOOL CERTIFICATION
503-378-5090
503-378-2157 fax
state.parking@oregon.gov
New Carpool/change in primary (First time certification)
Semi-Annual Recertification
Add Rider(s)
Remove Rider (Name of rider to remove)
Primary (please print)
Name
Employee ID
(Non-state employees, enter last 4 digits of SS #)
Agency/Division/Section/Unit
Agency ID
Physical Work Address
Work Phone
Ext.
Email
Primary Vehicle Identification Information:
1) Make
Model
Year
State
Plate
2) Make
Model
Year
State
Plate
3) Make
Model
Year
State
Plate
I carpool at least two-thirds of the working days each calendar month with the individual(s) listed below.
*
I agree to comply with the administrative rules in OAR 125-090, and specifically 125-090-0030.
*
I understand that I cannot be registered concurrently in any other carpool or Smart Commuter Program, nor
*
lease concurrently a monthly parking space or permit for any other DAS-controlled, public or private facility.
Failure to comply with the rules may subject all individuals in the carpool to citation, prosecution and/or
*
cancellation of parking privileges at state owned parking lots.
Signature
Date
Rider (please print)
Name
Employee ID
(Non-state employees, enter last 4 digits of SS #)
Agency/Division/Section/Unit
Agency ID
Physical Work Address
Work Phone
Ext.
Email
Rider Vehicle Identification Information:
1) Make
Model
Year
State
Plate
2) Make
Model
Year
State
Plate
3) Make
Model
Year
State
Plate
Signature (see above*)
Date
U:\PKG\Forms\CarpoolCertification.docx
Updated 8/25/2017 ICD
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form W-9 (substitute) - Request For Taxpayer Identification And Certification - Oregon Department Of Administrative Services
Financial
Monthly Transit Payroll Deduction Enrollment Cherriots / Carts / Commuter Club / Oregon Coachways - Oregon Department Of Administrative Services
Legal
Position & Personnel Database (ppdb) Temporary Service Worker Request Form - Oregon Department Of Administrative Services
Legal
Related Categories
Parent category: Legal