Participant Withdrawal & Transfer Form

Participant Withdrawal & Transfer Form
WITHDRAWAL

As much as we hate to see you go, you may withdraw from a Pierce Transit vanpool at any time.

There are two steps to complete your exit from vanpool. Both steps must be completed by the 20th of the month or you will still be responsible for the upcoming month's fare:

1) Complete and submit this form.

2) Notify your vanpool bookkeeper of your intent to withdraw from the group.

Until both steps are completed, your vanpool agreement will remain in effect and you will be responsible for the upcoming month's fare.

TRANSFER

You may transfer to a different Pierce Transit vanpool group at any time. Please complete and submit this form to initiate your transfer.

In order for your monthly statement to reflect the fare of the group you are joining in the upcoming month, your transfer form must be submitted by the 20th of the month.

Thank you for choosing to commute with Pierce Transit!
Name *

First Name Last Name
Email *
I am withdrawing from vanpool group number: *
Today's date: *

Month Day Year
Date
My last day on the van will be: *

Month Day Year
Name of your group's Primary Driver or Bookkeeper: *
Reason for withdrawing or transferring: *

Shift change Retiring Unresolved vanpool issues Transferring to different Pierce Transit vanpool Transferring to another agency Other
Which Pierce Transit vanpool group are you transferring to? *
Please list vanpool group identification number.
When are you starting with your new vanpool group? *

Month Day Year
Which transit agency are you transferring to? *
Please list the name of the transit agency you will be commuting with.
Why are you withdrawing or transferring?
Signature *

This form will not be accepted without a signature. Clear
Should be Empty: