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First Name:	*
Last Name:	*

Phone:	* (123-456-7890)
E-Mail:	*
Password:	*
Confirm Password:	*

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Street Address or Nearest Intersection:	* (if applicable please include NW, NE, SW, SE)
City:	*
State:	*
Zip:	*

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Company Name:	*
Company Street Address:	*
Usual Mode of Transportation:	*
Length of one-way commute:	* (in miles) Enter a number!

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Are you interested in receiving information on any of the following?	Yes	No	Already Involved
Lloyd Links (Personalized commute planning)
If you said ‘Yes’ to personalized commute planning above, please give some details
What type of personalized commute plan would you like? (Check all that apply) Transit Carpool Biking Walking What time do you need to be at work? 1 2 3 4 5 6 7 8 9 10 11 12 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM Are there any special requests for you commute plan? (e.g. need to stop at daycare before work) What time do you normally leave work? 1 2 3 4 5 6 7 8 9 10 11 12 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM Are there any special requests for you commute plan? (e.g. need to stop at daycare after work)
Are you interested in receiving information on any of the following?	Yes	No	Already Involved
Lloyd TMA Committees (bike, ped, transportation, marketing)

How did you hear about this program?
Friend/Co-Worker Web Transportation Coordinator Other Please fill this field!

Why do you use your current mode of transportation? Please fill this field!
(ex.. exercise, free, need to pick up kids from carpool)

How would you characterize yourself as a bicyclist?
Experienced Beginner Potential Not a Rider

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Please read each guideline below.

1. Must be a Lloyd District employee.
(West from the Willamette River, East to 16th, North to Broadway, and South to I-84)

2. All information provided by participants will be kept confidential and used for Lloyd Transportation Management (LTMA) purposes only.

3. The LTMA has the right to terminate this program with or without notice at any time for any reason.

4. A carpool arrangement must include two or more working adults commuting to work. Transporting children to school and/or day care will not qualify you for the incentive.

5. It is a condition of your participation in Lloyd Commuter Rewards that all information supplied by you will be correct, current, and complete.  The LTMA has the right to refuse your participation in this program, including the right to withhold payment of your incentive, if we believe you have failed to meet this obligation. We reserve the right to contact you and your supervisor to verify the information provided.

6. If a dispute arises regarding any aspect of the Lloyd Commuter Reward's program, including, but not limited to, interpretation of the Program Requirements, accuracy of the information provided by you, or your eligibility to participate in the program, The Executive Director of the LTMA shall be the final decision-maker regarding such a dispute. Any decision by the Executive Director will be final.

TO UPDATE YOUR PERSONAL INFORMATION, PLEASE CONTACT THE LLOYD TMA AT MAIL@LLOYDTMA.COM SUBJECT: COMMUTER REWARDS.

I have read and agree to the guidelines outlined on this page.
You must agree to the terms!