Submit completed form and all supporting documents to SmartPass@vta.org.2019 Smartpass Agreement • October 31st, 2018 • California
Institution Name (Provide DBA or prior Institution name, if applicable) Billing Address (Street, City, State, ZIP Code) If your organization has a federal tax-exempt status, provide your tax ID number and/or any supporting documents (e.g., an affirmation letter from the IRS, which may be obtained atwww.irs.gov/charities-non-profits/exempt-organizations-affirmation-letters). Tax ID # (please do not enter your Social Security Number): FOR VTA USE ONLY Location Address Headcountper Location † Standard orExpress Pass Service Level Annual RatePer Person Amount a. b. c. d. Agreement Period Blank Clipper® Card Quantity(if needed) Clipper® Per Card Fee Order Total Start Date End Date $3.00 Total Amount Due
