Vanpool Withdrawal/Transfer Form
A participant may choose to withdraw from the vanpool at any time; however, written notice to the STA Vanpool Office and the vanpool bookkeeper is required at least
ten days
before the start of the next month. Monthly fares are charged in advance up until a withdrawal form is submitted.
I am withdrawing from Group:
*
Group number (ex: V025) or Van number (ex: R126)
My last day of ridership will be:
*
-
Month
-
Day
Year
Date
Are you leaving the program or transferring to a different vanpool?
I am withdrawing from the Vanpool Program
I am transferring to a different group
Why are you withdrawing? Please check all that apply:
Unresolved Vanpool Issues
Shift Change
Retiring
Physical Address Change
New Worksite
Other
Please keep me active for future ride matching opportunities
May we contact you about your experience with Vanpool?
Preferred contact information
My new group number is:
Group number (ex: V025) or van number (ex: R126)
Main driver/bookkeeper for this van:
First and Last Name
I am an approved driver and I would like to keep my driving privileges
New Pick-up Stop
New Drop-off Stop:
*Fairchild AFB – use cross streets only – (do not use physical address or Bldg #s)
Driver/Bookkeeper for CURRENT van
*
First Name
Last Name
I have informed the main contact listed above of my withdrawal
Participant Name
*
First Name
Last Name
Participant Signature
*
Today’s Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: