Submit completed form and all supporting documents to smartpass@ibigroup.com.2023 Smartpass Agreement • October 4th, 2022 • California
Institution Name (Provide DBA or prior Institution name, if applicable) Billing Address (Street, City, State, ZIP Code) Federal Tax Identification Number (If your organization has federal tax-exempt status, provide your tax ID number and any supporting documents. For more information on acceptable documents, visit www.irs.gov/charities-non-profits/exempt-organizations-affirmation-letters). Coordinator Contact Information (Full Name, Title, Email Address, Phone Number) Primary Coordinator: Back-up Coordinator: Miscellaneous Do you require a Purchase Order to process payments?If yes, please include the PO number here: □ Yes □ No FOR VTA USE ONLY(To be completed by VTA staff) May VTA identify you as a member of the SmartPass Program in promotional material? □ Yes □ No SmartPass Category Are you required by a local city ordinance to enroll in a transit program such as the SmartPass Program? □ Yes □ No Address of Each Participating Facility Headcount perFacility† Service Level Annua
