Submit completed form and all supporting documents to SmartPass@vta.org.2020 Smartpass Agreement • October 16th, 2019 • California
Institution Name (Provide DBA or prior institution name, if applicable) Billing Address (Street, City, State, ZIP Code) Federal Tax Identification Number (If your organization has federal tax-exempt status, provide your tax ID number and any supporting documents. For more information on acceptable documents, visit www.irs.gov/charities-non-profits/exempt-organizations-affirmation-letters). Coordinator Contact Information (Name, Title, Email, Phone) Primary Coordinator: Back-up Coordinator: Miscellaneous Do you require a Purchase Order to process payments? □ Yes □ No FOR VTA USE ONLY May VTA identify your Institution as a member of the SmartPass Program inpromotional material? □ Yes □ No SmartPass Category: Is your Institution required by a local city ordinance to enroll in a transit program such as the SmartPass Program? □ Yes □ No Location Address Headcountper Location† Service Level Annual Rateper Person Amount a. b. c. Agreement Period Quantity
