Date (mm/dd/yyyy):
Organization Name:
Address:
City:
State:
Zip:
Contact Name:
Phone:
Fax:
E-mail Address:

1. Is your location a:
   Headquarters Location
   Branch Office
   Other (explain below)
2. If you answered 'other' in #1, where else does your company have locations:
   
3. What is the nature of your company's business?:
    
4. Number of employees at your business site:
    
5. Is your business:
   Private
   Non-Profit
6. Does your business location have any employees currently teleworking on a regular basis from home or a telework center?:
   Yes
   No
   
   If yes, how many from:

   Home:

   Telework Center:
7. Does your company have a formal telework policy in writing?:
   Yes
   No
   If yes, please upload a copy in Word (.DOC) or Acrobat (.PDF) format:
   
8. Please check all other employee transportation benefit programs provided by your company to employees at this location:
   Transit Subsidy (example Metrochek)
   Flexible Hours
   Compressed Week
   Preferential Parking for Car/Vanpools
   Shuttle Service
   Guaranteed Ride Home
   Other

Letter of Intent
Your application must be accompanied by a brief letter from an authorized senior level decision-maker of your company describing why the organization is interested in implementing a telework program and what the company hopes to accomplish through teleworking. Please attach your letter in Word (.DOC) or Acrobat (.PDF) format:

Who is the Senior Officer providing this description?:
 

This application constitutes a submission to initiate a formal company telework program on behalf of the business organization listed above. The Telework!VA Program applications are submitted through a competitive process, are subject to eligibility guidelines and will be awarded at the discretion of the Commonwealth of Virginia Department of Rail and Public Transportation on a first come/first serve basis as long as funds are available. They are normally processed within 10 working days.

If you have any questions or need assistance with this form, please contact Jennifer Thomas Alcott, (866) 469-1010 or info@teleworkva.org.