Name
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E-mail
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Phone
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How did you get to work on the date of your Guaranteed Ride Home?
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Carpool
Vanpool
Bus
Bicycle
How did you get home?
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Taxi
Transportation Company (Uber or Lyft)
Date and time of your ride home
Starting/pick up address
Destination/drop off address
Reason for ride
You or an immediate family member suffered an illness, injury, or severe crisis
Your carpool or vanpool vehicle broke down
Your carpool or vanpool driver had to leave early or stay late
You had to respond to an emergency at your residence
Your commute bicycle broke down on way to/from work
You were asked by supervisor to work unscheduled overtime (supervisor confirmation required)
Other (Please detail in “provide additional details” section)
Reimbursement request cost (in $):
Please provide any additional details about your trip that may be pertinent for the GRH program staff.
Where would you like your reimbursement check sent?
Address
City
State
Zip Code
Please include a copy of your ride receipt. The receipt must include information such as date, time, origin, destination, service provider and cost. Reimbursement requests (including receipt) must be submitted within 10 days of GRH trip date.
By submitting this form, you certify that all the information stated above is true. The GRH program has the right to request additional documentation or information, if needed. If the program administrator determines the use of GRH was invalid, no reimbursement will be issued. You are eligible to take a trip three days after registration.
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