Employer Application

Name:

Company Name:

Work Address:

Contact:

Number of Employees:

I'm interested in(check all that apply)...

Workplace-wide Emergency Ride Home partnershipWorkplace vanpool programExclusive workplace ridematchingParking demand reduction strategiesEmployee commuter benefit developmentPromoting commuter services within my workplaceOther

Apply for the Emergency Ride Home Program

How do you currently commute to work? You must select one to be considered for the program. If you do not currently use one of these modes of transportation, please reapply when you do. *

---BikeBusCarpoolGohio Commute VanpoolWalking

Name *

Email *

Contact Phone (required for the program) *

Home Address *

Employer *

Work Address *

Do you already have a Gohio Commute account?

Select OneYesNo

Typical Work Hours

How did you hear about us?

Select OneDigital AdvertisementEmployerEventGohio Commute BrochureInternet SearchWord-of-mouthOther

Voluntary Demographic Information

In an effort to improve our program, we are asking participants to complete the following questions, strictly on a voluntary basis.

Age

Select One18-2526-3536-4546-5556+

Race/Ethnicity

Select OneAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian or Other Pacific IslanderTwo or more racesWhite

Annual Income

Select OneLess than $10,000$10,000-$20,000$20,000-$30,000$30,000-$40,000$40,000-$50,000$50,000+

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