Get Gsa Form 2941

U.S. GSA Form gsa-2941 PARKING APPLICATION See Privacy Act Statement on reverse TOUR OF DUTY TIME TO FROM TYPE OF APPLICATION Check one TYPE OF PERMIT REQUESTED Check one SES Vanpool Individual Carpool Handicapped Government-owned PAGE OF PAGES PRESENT PERMIT NUMBER Motorcycle New Revision CARPOOL DATA If more than 5 members in pool use reverse and if necessary attach additional forms. NAME AND HOME ADDRESS List Applicant first then each member EMPLOYER/ AGENCY GSA CORRESPONDENCE SYMBOL OFFICE TELEPHONE NUMBER Include Area Code LENGTH OF GOVERNMENT SERVICE NO. OF ONE WAY TRIPS EACH WEEK IN CARPOOL DISTANCE ONE WAY HOME/ PICKUP PT. AUTO INFORMATION YEAR MAKE AND MODEL STATE AND TAG APPLICANT CERTIFICATION SIGNATURE OF APPLICANT I CERTIFY THE STATEMENTS MADE ON THIS APPLICATION ARE TRUE AND I WILL NOTIFY THE PERMIT ISSUING OFFICE WHENEVER A CHANGE OCCURS IN THE INFORMATION GIVEN IN THIS APPLICATION* I ALSO AM AWARE THAT ANY FALSIFICATION MAY RESULT IN THE LOSS OF THE PRIVILEGE OF PARKING FOR THE ENTIRE CARPOOL/VANPOOL FOR AT LEAST SIX MONTHS AT A FEDERAL INSTALLATION AND OTHER PENALTIES MAY BE IMPOSED AS PRESCRIBED BY LAW DATE OF APPLICATION FOR FALSIFICATION AND MISREPRESENTATION OF DOCUMENTS* FOR ADMINISTRATIVE OFFICE USE ONLY PERMIT APPROVED Signature GENERAL SERVICES ADMINISTRATION PREVIOUS EDITION NOT USABLE DATE ASSIGNED LOCATION NUMBER OF POINTS GSA FORM REV. 12/2003 MEMBER CERTIFICATION I certify that I am a regular driver/rider in the vanpool/carpool described on the reverse and that the information pertaining to me is true. I am aware that any falsification may result in the loss of the privilege of parking for at least six months at a Federal installation for the entire vanpool/carpool membership* SIGNATURE In compliance with the Privacy Act of 1974 the following information is provided Solicitation of the information is authorized by the Federal Property and Administrative Services Act of 1949 as amended and Title 5 U*S*C. General* Disclosure of the information is voluntary. The information will be used for the purpose of allocating parking spaces and used by GSA officers and employees who have a need for such information in the performance of their duties. Information will be transferred to appropriate Federal State local or foreign agencies when relevant to civil criminal or regulatory investigations or prosecutions or pursuant to a request by GSA or such other agency in connection with the firing or retention of an employee the issuance of a security clearance the investigation of an employee the letting of a contract or the issuance of a license grant or other benefit. If some or any part of the requested information is not provided on the form the individual would not be eligible for a parking permit if other requirements were met. NAME AND HOME ADDRESS List Applicant first then each member EMPLOYER/ AGENCY GSA CORRESPONDENCE SYMBOL OFFICE TELEPHONE NUMBER Include Area Code LENGTH OF GOVERNMENT SERVICE NO. OF ONE WAY TRIPS EACH WEEK IN CARPOOL DISTANCE ONE WAY HOME/ PICKUP PT. AUTO INFORMATION YEAR MAKE AND MODEL STATE AND TAG APPLICANT CERTIFICATION SIGNATURE OF APPLICANT I CERTIFY THE STATEMENTS MADE ON THIS APPLICATION ARE TRUE AND I WILL NOTIFY THE PERMIT ISSUING OFFICE WHENEVER A CHANGE OCCURS IN THE INFORMATION GIVEN IN THIS APPLICATION* I ALSO AM AWARE THAT ANY FALSIFICATION MAY RESULT IN THE LOSS OF THE PRIVILEGE OF PARKING FOR THE ENTIRE CARPOOL/VANPOOL FOR AT LEAST SIX MONTHS AT A FEDERAL INSTALLATION AND OTHER PENALTIES MAY BE IMPOSED AS PRESCRIBED BY LAW DATE OF APPLICATION FOR FALSIFICATION AND MISREPRESENTATION OF DOCUMENTS* FOR ADMINISTRATIVE OFFICE USE ONLY PERMIT APPROVED Signature GENERAL SERVICES ADMINISTRATION PREVIOUS EDITION NOT USABLE DATE ASSIGNED LOCATION NUMBER OF POINTS GSA FORM REV.