February 2011 Monthly Bus Pass Application
Contact Information: (All information is required: Please print clearly)
_____________________
_________________________
_________________________
Last Name
First Name
Email Address
_________________________
__________________________
_______________________________
Cell Phone
Home Phone
Student ID#
All applicants will be contacted January 21st-25th. What is the best way to reach you during these dates?
Please explain any activities you are involved in:
Job (Part Time/Full Time):
Clubs or Sports:
Civic Engagement or Environmental advocacy work:
(i.e. political, community or volunteer work)
Tell us about yourself (Max for each question 250 words):
1. Please explain if you are in need of financial assistance. (Please Include the following: current transportation
expenses, alternative monthly expenses (i.e. rent, utilty costs) and any other financial hardships.
Email your completed application including a current De Anza schedule and DASB ID image to DASBES@deanza.edu.
Transportation passes are allocated based on limited supply. By filling out this application you are also agreeing to
participate in future surveys.
All applications and images must be received by 11:59 pm January 21th,2011.
2. Please describe your commute to De Anza Community College. (Include bus/train/transfers/carpooling if
applicable).
3. Describe how you think using alternative transportation will lessen your impact on the environment.
4. How did you hear about this program?
Email your completed application including a current De Anza schedule and DASB ID image to DASBES@deanza.edu.
Transportation passes are allocated based on limited supply. By filling out this application you are also agreeing to
participate in future surveys.
All applications and images must be received by 11:59 pm January 21th,2011.
!Application will be denied if the following steps are not completed!
Step 1: Paste a PRINT-SCREEN image of your Winter 2011 DeAnza course schedule. (The image must be a snapshot
throught the DeAnza Registration website. Please go to http://www.seoconsultants.com/windows/print-screen/ for
help with Print-screen method):
Step 2. Paste a scanned image of your current DASB ID Card (Scanning services are available on-campus in the
Library--West Computer Lab located in the building basement behind main library.
http://www.deanza.edu/library/librarywestcomputer.html):
If you have any questions feel free to find us. The Senate office is under the cafeteria in the Hinson Campus Center.
Phone: 408.864.8694
For Official Use Only
Received by:_________________________________________ Date: January ____, 2011
Approved by:_______________________Print Name:_____________________________
Pass Valid for the month of: FEBRUARY 2011
Email your completed application including a current De Anza schedule and DASB ID image to DASBES@deanza.edu.
Transportation passes are allocated based on limited supply. By filling out this application you are also agreeing to
participate in future surveys.
All applications and images must be received by 11:59 pm January 21th,2011.