Staffordshire Share-A-Lift Company registration form by NWiF1Ybs

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									                           Staffordshire Share-A-Lift Company Registration Form

 Company:

 Company Representative:
 _______________________________________________________
 (This person may be asked to act as a local administrator on the scheme to verify employee identities )

 Telephone:

 Email:

 Company Email domain (e.g. @xyz.co.uk):

 Are you happy for staff to join with a non work email address if they choose to? Yes / No

 Number of employees:

 Full Address details of all sites: (if you require more space please photocopy this form)
Address 1:                                    Address 2:




Postcode:                                                  Postcode:
Address 3:                                                 Address 4:




Postcode                                                   Postcode:

     Do staff have a works Email address? (please circle):                        ALL                 SOME   NONE

     Signed:                                         Print name:

     Job Title:

     Please return by post or fax to:
     Sonia Atkins / Jeannie Hoddinott
     Staffordshire County Council
     DSD
     Sustainable Travel Team
     Transport Projects
     Riverway
     Stafford
     ST16 3TJ                                        TEL: 01785 276517                 FAX: 01785 276621

								
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