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 an expression of organizational interest in Telework!VA and does not constitute a binding agreement to participate in the program. All Telework!VA Program applications are subject to eligibility guidelines and will be awarded at the discretion of the Commonwealth of Virginia's Department of Rail and Public Transportation on a first-come, first-served basis, subject to availability of funds.

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