County of Orange - Club Rideshare Application

County of Orange - Club Rideshare Application

These rideshare incentives and programs are for County of Orange and Orange County Superior Court employees. The Program Guidelines are on the OC Rideshare website and include information about eligibility and incentive details. Certain incentives are reported as income. Start-up incentives are provided one‐time per mode.

If you have any questions about this application or any of the listed programs please reach out to the County of Orange Rideshare Office at: rideshare@ocgov.com or 714-834-7600.

First Name*

Middle Initial

Last Name*

Employee ID Number*

Email*

Work Phone Number*

Phone

Agency/Dept Name*

Bldg/Room Number

Work Street Address*

Work City*

Work Zip*

Carpool/Vanpool Matching – this is for employees interested in finding a potential carpool or vanpool match list.

Add me to the County of Orange ridematch.info database and match me with other County of Orange/Superior Court

employees for a potential carpool or vanpool.

Cross Streets Near Home

Home City

Home Zip

Work Start Time

Work End Time

Try Train/Bus – this is a 3‐month start‐up incentive for those that want to try taking the train or bus to work:

Reimburse me for up to 3‐months of riding the train or bus (75% for first month; 50% for second month; and 25% for third month). I have attached all three months of receipts/proof of purchase to this form and I have not received this incentive in the past nor have I used this mode to commute to work during the last 90 days. This is a one‐time incentive.

Start A New Vanpool – this is a $300 start‐up incentive for those that lease a vanpool vehicle to commute

I certify that I have leased a vanpool, from a third‐party vendor, to share the commute with four or more employees.

Please send me the required Vanpool Information Form where I will list the roster, route and vehicle lease information.

Get Charged – this is a $100 bonus incentive for those that lease/purchase a zero emission, EV or Plug‐in EV

In the last 90 days I have leased/purchased a zero emission, electric or plug‐in EV to commute to work: Please provide the make, model, and the date of purchase (Attach copy of lease/purchase agreement). This is a one‐time only incentive. Includes hydrogen fuel‐cell vehicles.

Make:

Model:

Date Purchased:

Club Rideshare – this is a $40 incentive for employees who register and track 20 rideshare event dates

I am a first‐time registrant in Club Rideshare and tracked 20 dates where I commuted to work by carpooling, vanpooling, bus, train, bicycle, walking, telecommuting or driving an ZE/EV/PHEV in the last 90 days. This is a one‐time incentive and not available to employees that have received the Try Train/Bus, Get Charged, or Start A New Vanpool incentives. See the Program Guidelines for additional details. Please provide the dates below.

Date 1

Date 2

Date 3

Date 4

Date 5

Date 6

Date 7

Date 8

Date 9

Date 10

Date 11

Date 12

Date 13

Date 14

Date 15

Date 16

Date 17

Date 18

Date 19

Date 20

How do you currently commute to work?

Select or enter value

Attachments:

Please add any requested attachments here.

Drag and drop files here or

By submitting this form, I acknowledge that I have read the OC Rideshare Program Guidelines and I understand that the above information can be used to organize carpools, vanpools or distribute requested incentives. Employee ID numbers are required and that certain incentives will be payroll events and will be reported as income.

I understand*

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