Airtel Subscriber Enrollment Form Pdf

Enrollment Application
Employer Information (please print or type)
Company Name
Address
City
State
Contact Information (senior manager on site)
Title
Phone
Fax
Zip
Email
Type of Business (check one)
For Profit
Non-profit
Order Information
Total Employees at Participating Work Site(s) ________
Maximum Monthly Direct Benefit Per Employee $________
Estimated Total County Contribution Amount $________
Estimated Number of Participating Employees ________
Under Federal law, employers may provide up to $255 monthly to
each employee as a tax-free benefit. Consult your tax advisor for
additional information.
Employer Agreement
As a participant in the FareShare Program, we agree to the following program guidelines:
•
We will provide a tax-free monthly transit/vanpool benefit of up to $255/month to each employee working at our Montgomery County
location(s) who takes transit or a vanpool to work. Montgomery County will provide a matching amount of up to
$50/employee/month to each eligible employee and a maximum of $10,000 over a 12-month participation period.
•
We understand that if we currently provide a transit/vanpool benefit and it is less than the Federal maximum of $255/month, the
County will match any increase in the benefit up to $50/month, with a $10,000 maximum in one year.
•
Transit and vanpool benefits must be offered through Metro’s SmartBenefits© program and are for use only by our employees
working in Montgomery County in a Transportation Management District (TMD).
•
We will place our company’s SmartBenefits© orders on a monthly, quarterly or as needed basis and provide payment in full to
Metro at the time of purchase.
•
We agree to submit the Employer Worksheet Invoice and the SmartBenefits© Order Confirmation Form to Montgomery County for
reimbursement of the matching amount of funding provided under the FareShare program.
•
We understand this is a 12-month program, beginning with the date of receipt of our first order.
•
All employees at our Montgomery County location(s) will be asked to complete a commuter survey at the beginning of our
participation in the Fare Share Program and during the following year, to evaluate the impact of the program.
•
We understand that continuation of this program is contingent upon availability of funding.
____________________________________________________________
________________________________
Authorized Representative
Date
(Name & Title)
For Dept. of Transportation Use Only
Representative
Date Received
First Order Date
TMD
Revised 8/11/16