Transitchek Order Form Page 4
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4Employer Order Form
BILLING INFORMATION
Make check payable to:
Commuter Benefit Program
Getting on board with TransitChek is easy. Employers simply fill out this
order form and select a payment option.
Mail to:
Commuter Benefit Program
c/o CCS Corp./Accor Services
This form is for employers not yet enrolled in TransitChek. If you have ordered
51 Water St., 2nd Floor
TransitCheks before and have an existing account, please check this box. ❏
Watertown, MA 02472
IMPORTANT NOTICE for PATCO riders—NEW PROCEDURES
EMPLOYER SHIPPING INFORMATION
(if different from billing)
If employees ride PATCO and use FREEDOM Cards, their employer must now submit
Company name __________________________________________________________
a separate spreadsheet for an electronic transfer of funds to the employees'
FREEDOM Card accounts. Forms can be obtained online ( ),
Title ___________________________________________________________________
by phone (215-592-1800), or by emailing us at . New orders
Street address __________________________________________________________
for both paper vouchers and FREEDOM Card loads must be submitted on this
(No delivery to P.O. boxes or P.O. box ZIP codes)
order form with one payment.
Suite/floor/room_________________________________________________________
Company name __________________________________________________________
City _________________________________________State_______ZIP____________
Contact ________________________________________________________________
Phone (important) _______________________________________________________
Title ___________________________________________________________________
Fax____________________________Email____________________________________
Address ________________________________________________________________
You may request an invoice, but orders are only shipped after payment is received.
Suite/floor/room_________________________________________________________
❏ Payment is enclosed, ship immediately
City _________________________________________State_______ZIP____________
❏ Send invoice (delays order)
Phone (important) _______________________________________________________
Fax____________________________Email____________________________________
FUTURE ORDERS
To receive a reorder notice, check the appropriate option below. (Not available
ORDER COSTS
for monthly orders; use shipping sheet for next order.)
Each TransitChek voucher is valid for 13 months from shipment. There is a service fee of
We expect to order more TransitCheks in:
2% of the total cash value of your order, plus a shipping and handling fee (see below).
_____3 months _____6 months _____12 months
A
B
C
Voucher
Voucher
TELL US MORE
Denomination
Quantity
Value (A x B)
How many employees does your company have? _____________________________
$15
x
_______
___________
How many employees will be using TransitChek?* ____________________________
$20
x
_______
___________
$21
x
_______
___________
May we identify your company as a participant in TransitChek?
Yes
No
$30
x
_______
___________
In what industry category is your company? _________________________________
$35
x
_______
___________
_______________________________________________________________________
$60
x
_______
___________
*Note: Employee information flyers are sent with your first order.
$65
x
_______
___________
DO YOU HAVE ANY QUESTIONS?
PATCO FREEDOM Card total amount
+ ___________
For general information or questions about placing an order, call
215-592-1800.
(separate sheet)
Subtotal ___________
For customer service or information on the status of your order, call 800-531-2828.
Add 2% service fee
x ___________
(multiply subtotal x .02)
Delaware Valley
$12 ___
Add $12 for shipping and handling
+
(allow 3 weeks to receive first order)
Option: Add $15 for expedited delivery
___________
Getting to work can be a lot less taxing.
(order will arrive approx. 1 week sooner)
Total Cost $ ___________
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Parent category: Business