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CARPOOL PARKING APPLICATION
(This is not an on-line application. However, you can type in the boxes provided, print, and send the application)

CSS USE ONLY:

CSS VALID NO:

VALIDATED BY:
NO. OF PERSONS IN POOL: GARAGE NUMBER:
ALL MEMBERS OF THE CARPOOL MOST RESISTER WITH THE COMMUTER SERVICES OFFICE AND OBTAIN A VALIDATED CARPOOL APPLICATION.

A CARPOOL MUST CONSIST OF TWO (2) 0R MORE PERSONS, COMMUTING A MINIMUM OF THREE (3) DAYS PER WEEK.

THE COMPLETED, VALIDATED APPLICATION MUST BE PRESENTED IN PERSON TO THE PERMIT SALES OFFICE.

Last Name:  First Name: Middle Initial:
Mailing Address:  
Home Address:
Home Phone: Work Phone: Ext:
Carpool: Van Pool: Work Hours:
to
CERTIFICATION:

I certify that I am the principal driver of the carpool with the Individuals indicated in this application and that I commute to and from work with them on a regular basis, a minimum of three (3) days a week. Should any changes occur (additions, deletions or replacements), I agree to notify the Commuter Services Office Immediately. I have read and agree to abide by the Preferential Carpool Permit Program Rules with the understanding that violations on my part may result in the cancellation of the permit. I acknowledge that should any of the information relating to the carpool of which I am a member be found to be untrue, the carpool's special parking privileges will be revoked. I understand that this permit is valid only at the designated facility in specifically assigned CARPOOL areas or at any Long Term (9 hours or more) meters within the designated facility.

Signature:_______________________________________ Date:__________________________
Official Use Only:
Control# _______________ Account# ________________ Fees $_________________

MONTGOMERY COUNTY, MARYLAND
PARKING SALES AND COLLECTIONS OFFICE
809 ELLSWORTH AVENUE (within Garage 61)
SILVER SPRING, MD 20910
MAIN: 240-777-8744   FAX: 301-565-5898

 

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