First Name*

Last Name*

Home Address

City

State

Zip Code

Home Phone* enter at least one phone

Work Phone*

E-mail Address*

Have you ever ridden Tri-Rail before? Yes   No

If "Yes," how often do you ride? -- select a range -- Daily 2-3 times a week 2-3 times a month Once a month

What was the purpose of your trip? (check all that apply) Work  / School  / Special Event  / Airport  / Leisure

If "No," what would help you in choosing to ride? (check all that apply) Low Fares  / Convenient Schedule  / Station Locations Connecting Service  / Traffic  / Gas Prices

Are you aware of the discounted fares available for: Yes   No    -  Students Yes   No    -  Children Ages 5 - 12 (Under Five Ride Free) Yes   No    -  Senior Citizens Yes   No    -  Medicare Card Holders Yes   No    -  Employer Discount Program Member Yes   No    -  Groups of 25 or More