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ERIC USE VERIFICATION 1 <br /> Please print legibly/, using ink. <br /> ENCY <br /> RIDE <br /> ome <br /> To be completed by UNIVERSITY'S Program Coordinator <br /> Date <br /> Employee Name <br /> Home Address <br /> City,Zip Code <br /> Company Name <br /> Reason Trip Requested <br /> Alternative <br /> Commute Mode Used on day of ERN <br /> Pickup Address <br /> 1st Intermediate Stop Place&Address <br /> If no intermediate stop,write NONE). (Please indicate home,school,daycare,hospital,ATM,etc.and address) <br /> 2nd Intermediate Stop Place&Address <br /> If no intermediate stop,write NONE). (Please indicate home,school,daycare,hospital,ATM,etc.and address) <br /> Program Coordinator Signature <br /> Program Coordinator Printed Name <br /> Mileage Verified by: \ Paid on: <br /> FareI <br /> Send original to Pierce Transit Make a copy for your records <br /> Mail completed form,with attached receipt,to: <br /> Pierce Transit <br /> Business Partnerships <br /> PO Box 99070 <br /> Lakewood WA 98496-0070 <br /> U-PASS Agreement {�9�e 38 of 44 Final, October 2011 <br /> Attachment 4, Emergency Ride Home Terms <br />