Free DT1200 - Wisconsin


File Size: 117.0 kB
Pages: 1
Date: March 12, 2010
File Format: PDF
State: Wisconsin
Category: Government
Word Count: 364 Words, 2,321 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/forms/docs/dt1200.pdf

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WISCONSIN RIDESHARE REGISTRATION
Wisconsin Department of Transportation DT1200 03/2010

Please complete, print, and mail or fax to: Wisconsin Rideshare PO Box 798 Waukesha, WI 53187-0798 Name and Origin
Last Name City First Name County

E-mail: karen.schmiechen@dot.wi.gov Phone: (262) 521-5454 Fax: (262) 521-4425

Clear form

Home Address* State

Apartment Number ZIP Code

If trip origin is different from home address, complete below
Origin Address (If Different from Home) Apartment Number City State ZIP Code

Destination
Employer / School City Check if Student County Address State Suite / Department ZIP Code

Work / School Hours
Start Time Minutes of Flexibility AM PM End Time AM PM Minutes of Flexibility



Profile Preferences
Current Transportation Mode For This Trip Drive Alone Carpool Vanpool Gender Male Female Transit Bicycle Walk I Have a Vehicle Yes No Avoid Smokers When Matching Yes No Match Only With Same Gender Yes No If Yes, Interested as Driver Rider If Yes, Interested as Driver Rider Either Either Prefer to Be Matched With Novice Experienced Either I am a Smoker Yes No

Carpool Interest? Yes No Vanpool Interest? Yes No Bike Buddy Interest? Yes No

Bicycle Skill Level Novice Experienced

Contact Information Please provide at least two contacts. An e-mail is required for online contact.
Area Code / Home Telephone Number* ( ) - Area Code / Work or School Telephone Number / Extension ( ) - Extension The Wisconsin Rideshare program allows potential partners to contact each other via text messaging. Users must agree to receive text messages, be responsible for text message charges, provide a cell phone number and identify a service provider so that messages can be properly routed. How Did You Hear About This Program? Area Code / Cell Telephone Number ( ) E-mail Permission to Send / Receive Text Messages? Yes No Name of Cell Phone Provider* Additional Information or Comments

*Home address, home telephone and cell phone provider are used for internal purposes and will not appear on matchlists. Thank you for your interest in the Wisconsin Rideshare program. Matchlists will be mailed or e-mailed if an e-mail address is provided. If you have Internet access, you may check for new matches at anytime through www.rideshare.wi.gov.

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