This Form Must Be on Your Company Letterhead to Be Valid

RTD 2014 ECOPASS AUTHORIZATION FORM

(This form must be on your company letterhead to be valid)

Form Must Be Completed Entirely By COORDINATOR use BLUE or RED ink to complete this form NO BLACK

Volunteers, temporaries, out of state, seasonal and retired or termed employees are not eligible

You MUST create a new rider for new employees in the web portal and write the RIDER ID assigned to the employee by the web portal below before sending them to one of our EcoPass Service Centers.

NEW ______REPLACEMENT ______NAME CHANGE______

$10 Replacement Fee Required No fee for name changes if the

old card is presented at time of photo

AGREEMENT AND SIGNATURE BY EMPLOYER

(Forms must have original signatures, be complete and must be dated within 30 days otherwise forms are not valid and photo will not be taken. Employee must show a driver’s license or government issued ID.)

Please issue an EcoPass to the following employee:

Employee: ______Company:

SLA: ______RIDER ID # assigned to rider in web portal:______

The above individual is currently an employee with the business indicated above. I have read and agree to the terms and conditions of EcoPass Contract and authorize this employee for an RTD EcoPass.

Authorized by: Date: ______

Coordinator Signature Required (Original no copies or stamps)

Printed Coordinator Name Phone

EcoPass Service Center Locations and Hours:

DOWNTOWN DENVER: 1600 Blake Street (RTD Administrative Offices)

·  Tuesday 10:00 a.m. - 1:00 p.m.

·  Thursday Noon - 3:00 p.m.

DOWNTOWN BOULDER: 1400 Walnut Street (RTD Bus Terminal)

·  Monday Noon - 4:00 p.m.

·  Wednesday Noon - 4:00 p.m. (September 01 thru February 28 only)

DENVER INTERNATIONAL AIRPORT: Level 5

·  Wednesday 12:30 p.m. - 1:45 p.m.

Photos will NOT be taken on the following days:

New Years Eve, New Years Day, Martin Luther King, Jr. Day, Presidents Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas Day

Revised: 11/04/13