Anaheim Transportation Network

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Anaheim's Clean Air Team
"CAT" Program
A Ridesharing Reward Program
Rideshare incentives for: Carpooling•Bicycling•Walking•Commuter Rail•Public Transit

(choose a month) Month Claim Form

Please complete one claim form per month per participant, 2 ways to submit this form:
1)	Anaheim Transportation Network, 311 East Center Street, Anaheim, CA 92805 Fax: (714) 563-5289
-or- 2)	Save time and postage. Fill out this form online and submit it now. Use the submit button at the bottom when you have completely filled in all required fields.

Returned claim form must be received at the ATN offices no later than the fifth (5th) day of the following calendar month to be eligible for "CAT" incentives. Start recording your ridesharing mode at the beginning of each calendar month. At the end of the month, please total your days of ridesharing and write the number in the total box below.

Name:	*required information
Company:	*
Work Phone:	* ex: (714) 555-1212

Use the following codes to indicate your commuting mode(s) to work each day:

B=Bicycle	C=Carpool	T=Telecommute
R=Commuter Rail	P=Public Bus	W=Walk	V=Vanpool

Please record your commute mode(s) for the month below:
Month/Year: / *

Week	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
1
2
3
4
5

1st Month Total Days You Rideshared:

If submitting via the internet click below to agree/certify that the above information you are submitting is correct and that you have met the requirements that fall under the provisions of Anaheim's Clean Air Team program.
I agree/certify: *

Click SUBMIT when you have completed all the required fields above ->

Information below this line is only required if printing this form out and submitting via fax or postal mail.

I certify that the above information is correct and I have met the requirements that fall under the provisions of Anaheim's Clean Air Team program.

Participant Signature: _______________________________

Date: __________________

Thank You!

FOR STAFF USE ONLY

Total # of Days Rideshared ___ Payment Amount ___ Payment Date ___ Processed by ___