Central 70 Globeville Elyria Swansea Tolling Equity Program Toll Credit Element Enrollment Form

Central 70 Globeville Elyria Swansea Tolling Equity Program Toll Credit Element Enrollment Form
If a friend or neighbor referred you to the program, please give us their first and last name so they can receive additional toll credit as a thank you:
First name / Last name
How did you hear about the program?*

flyertext messagefriends/familyGES GazetteExpressToll emailFacebook adother
Your name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
By submitting this form, you are agreeing to receive periodic SMS/text messages at the phone number you provide to alert you when money is added to your toll account. Reply STOP to opt out. Standard message and data rates apply.*

I accept these terms.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vehicle*
Plate number
Vehicle make
Vehicle model
Vehicle color
Preferred language*

EnglishSpanish
Proof of address*

driver license / Colorado ID / US passport; OR bill with name and address on it; OR tax returns; OR lease agreement
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Proof of income*

Medicaid; OR SNAP Benefits; OR LEAP Program; OR Free and Reduced School Lunch Program; OR tax returns; OR one month of pay stubs for all earning household members; OR other (please reach out to get prior approval if you have another document you'd like to use)
Cancelof
Car registration (may be registered outside 80126, as long as you can prove your 80216 residency)*

Cancelof
To read a fullscreen version of the terms & conditions, please visit https://www.netransportation.org/static-waiver
Date

MonthDayYear
Date
Signature*

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By submitting this application, you are applying for the program. If you’ve been accepted, a transponder package from BancPass will be mailed to your house within one month. Please follow the instructions in the package to start using program benefits.
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Central 70 Globeville Elyria Swansea Tolling Equity Program Toll Credit Element Enrollment Form

By submitting this application, you are applying for the program. If you’ve been accepted, a transponder package from BancPass will be mailed to your house within one month. Please follow the instructions in the package to start using program benefits.