Van Start/Van Save Application

Page One

The Van Start/Van Save programs subsidize empty seats over a defined period of time. Both programs are open to all vanpools that have trips that terminate in the City of Alexandria.

The Van Start program for vanpools is designed to provide incentive for new vanpool formations that have the City of Alexandria as their destination.

The Van Save program is designed to assist existing established vanpools with commutes that end in the City of Alexandria, that are experiencing an emergency loss of passengers.

Van Start / Save assistance will be granted at the discretion of GoAlex based on the eligibility of the applicant and demonstrated activity in recruiting passengers. The program provides up to $200 flat rate per eligible empty seat, per number of eligible months. See program details for eligibility requirements and financial assistance terms and conditions. Funding for this program is limited and is available only between October 1, 2013 – June 30, 2017, or until the funds are spent.

For more information or to apply, contact the GoAlex Van Start/Save program manager, Geralyn Taylor with GoAlex at 703-746-4084 or at geralyn.taylor@alexandriava.gov.

To view full list of Eligibility Requirements click HERE

For more information contact the GoAlex Van Start/Save program manager, Geralyn Taylor with GoAlex at 703-746-4084 or at geralyn.taylor@alexandriava.gov.

1. This applications is for *This question is required.

2. Please provide the following Vanpool Company Information *This question is required.

Company Name:
Company Contact:
Contact Phone:
Contact Email:
Contact Address:

3. Please provide the following vanpool information *This question is required.

Vehicle Make/Model/Type:
Vehicle Seating Capacity (including driver):
Vanpool Start Date:
Commercial Vanpool Insurance Provider:
Monthly Rider Fare:
Number of passenger seats currently filled by monthly riders:

4. Please indicate where riders are picked up in the morning? *This question is required.

Pick Up Point 1 (address):
Time arrive at Pick Up Point 1:
Pick Up Point 2 (address):
Time arrive at Pick Up Point 1:

5. Where are riders dropped off in the morning?

Drop off point #1 (address):
Time dropped off at point #1.
Drop off point #2 (address):
Time dropped off at point #2.

6. For Van Save Only: When did the monthly passengers leave the vanpool?

Passenger 1; Date:
Passenger 2; Date:
Passenger 3; Date:
Passenger 4; Date:

Application Certification

I CERTIFY AND AFFIRM: *This question is required.

That I will immediately notify the GoAlex Van Start/Save Program manager when I no longer qualify for this program;
That I am aware that the information I have provided is subject to review and verification;
That I am familiar with and will comply with all of the eligibility requirements and responsibilities stated in the program requirements;
That I have not requested or received financial assistance for this vanpool for the last 12 months;
That no more than 50 percent of the total riders in the vanpool have participated in the Van Start or Van Save program in the previous 12 months;
That the matters and facts contained in the foregoing application are true and subject to verification.
The City of Alexandria/GoAlex’s assistance to any vanpool under the Van Start/Van Save program does not constitute ownership or operation of any vehicle or control of any entity involved in the operation of a vanpool. The City of Alexandria/GoAlex assumes no liability for any vanpool program operated by any entity assisted pursuant to this program.

Applicant Name: *This question is required.

First:
Last:
Phone:
Email:

Vanpool Driver and Passenger List (Indicate Driver with a D or Driver, Before Name)

Space Cell	Name	Phone (555.555.1212)
1. *This question is required	Name	Phone (555.555.1212)
2. *This question is required	Name	Phone (555.555.1212)
3. *This question is required	Name	Phone (555.555.1212)
4. *This question is required	Name	Phone (555.555.1212)
5. *This question is required	Name	Phone (555.555.1212)
6 *This question is required	Name	Phone (555.555.1212)
7.	Name	Phone (555.555.1212)
9.	Name	Phone (555.555.1212)
10.	Name	Phone (555.555.1212)
11.	Name	Phone (555.555.1212)
12.	Name	Phone (555.555.1212)
13.	Name	Phone (555.555.1212)
14.	Name	Phone (555.555.1212)
15.	Name	Phone (555.555.1212)

7. Vanpool Coordinator or Owner/Operators: *This question is required.

Name:
Work Phone:
Alternate Phone: