Carpooling Makes $ense Registration Form

This registration form is for your entire carpool. A carpool is defined as two or more individuals, over 18 years old, sharing a ride to work, college or university. Only one member needs to register. Please make sure to fill in the names and contact information of the other carpoolers in your group in the fields below. All information will be verified.

After your registration is submitted, the appropriate Transportation Management Association (TMA) will contact you regarding procedures for verification and tracking. You will track your weekly commute in order to qualify for the gas card. Carpools must submit their carpool log within 120 days of registration in order to be eligible to receive the gas card(s).

Please fill out the form completely. All Items with an * are required fields.

If you have any questions concerning this form, contact the New Jersey Department of Transportation's (NJDOT) Ridesharing Office at 800-245-POOL (800-245-7665).

* Required fields

Carpool leader
* First name:
* Last name:
* Gender:	Male  Female
* Home address:
Apartment No:
* City:
* County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
* State:
* Zip:
Mailing Address (if different from above):
* Home phone:	(e.g. 000-000-0000)
Cell phone:	(e.g. 000-000-0000)
* E-mail:
Carpool leader's employer site
* Employer:
* Street address:
* City:
* County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
* State:
* Zip:
* Work phone:	(e.g. 000-000-0000)
Carpool leader's work and travel
* I usually arrive at work:	Select AM PM (e.g. 8:00 AM)
* I usually leave work:	Select AM PM (e.g. 8:00 AM)
* Days available for carpooling:	Mon Tue Wed Thu Fri Sat Sun
* Are your hours flexible:	Yes No
* Approximate one way trip mileage for your commute:
Other participants in carpool
* Member 1:
First name:
Last name:
Home address:
Apartment No:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Mailing Address (if different from above):
E-mail:
Company name:
Street address:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Work phone:	(e.g. 000-000-0000)
Member 2:
First name:
Last name:
Home address:
Apartment No:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Mailing Address (if different from above):
E-mail:
Company name:
Street address:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Work phone:	(e.g. 000-000-0000)
Member 3:
First name:
Last name:
Home address:
Apartment No:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Mailing Address (if different from above):
E-mail:
Company name:
Street address:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Work phone:	(e.g. 000-000-0000)
Member 4:
First name:
Last name:
Home address:
Apartment No:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Mailing Address (if different from above):
E-mail:
Company name:
Street address:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Work phone:	(e.g. 000-000-0000)
Member 5:
First name:
Last name:
Home address:
Apartment No:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Mailing Address (if different from above):
E-mail:
Company name:
Street address:
City:
County:	Select One Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Outside New Jersey
State:
Zip:
Work phone:	(e.g. 000-000-0000)
Comments:

* Eligibility Agreement - Terms and Conditions The Agreement box must be checked or the application will not be accepted.
	If you participated in any NJDOT Ridesharing Program and received a gas card, you are ineligible for this program. The incentives offered through this program are provided to applicants on a first come first serve basis. NJDOT may discontinue this program at anytime. A condition of participation in Carpooling Makes Sense is that all information supplied for both the carpool leader and carpool members is correct, current and complete. NJDOT has the right to refuse participation in the program and the right to withhold incentives if NJDOT believes the carpool leader has failed to meet this obligation. To qualify for the gas card, the carpool must carpool 24 days in a two-month period. Carpools must submit their carpool log within 120 days of registration in order to be eligible to receive the gas card(s). $200 maximum gas cards are offered for each carpool (one time offer). This offer cannot be combined with any other carpool incentive program that NJDOT offers.
I agree to all of the above terms and conditions.

Click on the "Submit" button below to send this form for processing.