CARPOOL APPLICATION FORM
U.S. DEPARTMENT OF COMMERCE
FORM CD-307
(REV. 09-98) LF
DAO 217-8
LOCATION (Assigned by OAO) ____________________________________
SUBMISSION DATE __________________________
NAMES
LAST, FIRST, MI
WORK
PHONE
COMPLETE WORK ADDRESS
(Include Room No. & Mail Route)
HOME ADDRESS
EMPLOYER/
AGENCY
AND BUREAU
NO. OF
MILES
FROM
RESIDENCE
TO HCHB
TAG
NUMBER
S
T
A
T
E
MAKE
OF
CAR
Y
E
A
R
DAYS
PARTICIPATED
TO & FROM
PER WEEK
TOTAL MEMBER RIDES ________________________
APPLICANT
RIDER’S
RIDER’S
RIDER’S
RIDER’S
RIDER’S
RIDER’S
1.
Carpools must contain at least three members.
CARPOOL POLICY
Applicant Signature and Printed Name
Date
Rider Signature and Printed Name
Date
Rider Signature and Printed Name
Date
Rider Signature and Printed Name
Date
Rider Signature and Printed Name
Date
Rider Signature and Printed Name
Date
Rider Signature and Printed Name
Date
CERTIFICATION
WARNING
The United States Code contains penalties for falsification of information or signatures, or inclusion of individuals not participating regularly as
carpool members. Please carefully read the certification before you sign. All items will be verified.
CERTIFICATION: We, the undersigned, certify with our signatures that the information provided on this form is true and accurate as of this date. We understand
that if this certification is false or fictitious in any material respect, we may be subject to criminal prosecution under 18 USC § 1001 (providing for potential
imprisonment and fines). Falsification of and/or misrepresentation in documents submitted under this program will lead to a mandatory minimum of six month loss
of parking privileges and may lead to Agency disciplinary action, up to and including removal from Federal employment.
4. Applicants are responsible for accuracy of the information and true signature of each
2. The applicant must be a full-time Commerce employee.
3. Carpools will be registered in the name of the Applicant.
carpool member.
HCHB