Carpool Certification - Oregon Department Of Administrative Services Page 2
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
Primary (please print)
Name
Employee ID
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 page 1*)
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 page 1*)
Date
th
Note: Carpools are recertified every March and September. Forms received by the 15
of the month will be effective from the first day of the
th
current month. Forms received after the 15
of the month will be effective the first day of the next month.
Carpool Boundaries
th
To qualify in SALEM: All participants must work within the CITY OF SALEM bounded by Market ST on the north, 17
ST on the east, Mission ST on the
south and the Willamette River on the west.
To qualify in PORTLAND: All participants must work within the CITY OF PORTLAND bounded by Hoyt ST on the north, the Willamette River on the
th
east, and I-405 on the south and west; and/or within the Lloyd District bounded by Broadway on the north, NE 16
on the east, I-84 on the south and
Martin Luther King Blvd. on the west.
th
To qualify in EUGENE: All participants must work within the CITY OF EUGENE bounded by Third ST on the north, Fairmount ST on the east, 24
ST on
the south and Washington ST on the west.
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