Guaranteed Ride Home Reinbursement Form

GUARANTEED RIDE HOME
USAGE FORM

We hope that CDTC's Guaranteed Ride Home Program has assisted you with your unexpected travel
needs. Completion of this form and verification by your employer/supervisor will insure that you
will be eligible to use the program again. If you fail to submit this form to CDTC, you will not be
provided another Guaranteed Ride Home.

1. Your name and address:
Name:____________________________
Street:____________________________
City/Zip:__________________________

2. Name and address of your employer:
Name:____________________________
Street:____________________________
City/Zip:__________________________

3. Name, title and telephone number of your supervisor?
Name:____________________________
Title:_____________________________
Telephone:_________________________

4. Date of guaranteed ride home:
_______________________________

5. Have you used CDTC's Guaranteed Ride Home service before?
YES_____ NO_____

If "YES", date(s) of prior usage______
_______________________________
_______________________________

6. How do you regularly commute to work?
____Carpool
____Ride the bus
____Walk or Bike

(Note: "regularly means three or more times per week, on average)

7. If you regularly carpool or take the bus, please identify the name
and phone numbers of your carpool partners or the bus company and route:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

8. For what reason did you need this guaranteed ride home?
____My illness
____Family illness
____Unscheduled Overtime
____Carpool partner had emergency
____Other (please explain)______________________
___________________________________________

9. To what location did you take this guaranteed ride home?
___________________________________________
___________________________________________
___________________________________________

10. What is the name and telephone number of the person who can verify your trip?
(This should be a supervisor, personnel officer, employee relations employee, etc)
__________________________________________
__________________________________________
__________________________________________

I affirm that the information I supplied above is true.

__________________________________________________
participant

__________________________________
date

I confirm that the information is true--that the person requesting reimbursement for this ride home
under the guaranteed ride home program needed the ride home for unplanned overtime
or an emergency and that this person regularly carpools, rides the bus, bicycles or walks to work
(or any combination thereof).

__________________________________________________
supervisor, personnel director, etc.

__________________________________
date

Mail completed form to: Capital District Transportation Committee, GRH Program, 1 Park Place Main Floor, Albany, NY 12205

GUARANTEED RIDE HOME USAGE FORM

GUARANTEED RIDE HOME
USAGE FORM