San Francisco Bay Area  
Are you a new customer?   Returning customers, please provide your customer number: ____________________  
COMPANY INFORMATION: cannot be processed unless all information is provided. Please fill out completely. Your order
Please fill out completely. Your order  
Company Name   Date      *
Contact Name/Title      *
Address (We do not deliver to P.O. Boxes or Box Zip Codes)   Suite/Floor/Room    * *
City   Zip   State * * *
Phone   Fax       *
Email (Important: To receive order and shipping confirmation)         *
SHIPPING ADDRESS IF DIFFERENT:    
   Company Name       
Address (We do not deliver to P.O. Boxes or Box Zip Codes)   Suite/Floor/Room   
City   Zip   State
PRODUCTS SELECTION CHART    
                 BART High Value Ticket   (Not Returnable/ Not Refundable)
             $30   $ $30 =    x                                                  
TransitChek ® Card, a prepaid Visa                 (Not Returnable/ Not Refundable)                                ® card
TransitChek® Voucher                           (Not Returnable/ Not Refundable)
         Denominations Quantity $15   $ $15 = Cost/ Item Total Cost x                                    
         Total (   $ )    +                                                  +               
       © 2010 TransitCenter, Inc. All Rights Reserved SFOF-0210
                                                           $60 ($64 in rides) $ $60 = x   
                                                                    $ BART Total
         Denominations Quantity Cost/ Item Total Cost
                    $35 $ $35 = x                                                    
                                 $45 $ $45 = x                                        
                                           $50 $ $50 = x                                 
                                                  $55   $ $55 = x                            
                                                                                      $60 $ $60 = x                       
                                                                                          $65 $ $65 = x
                                                                           $ TransitChek Card Total                                       
                  $30 $ $30 = x                                              
                              $35 $ $35 = x                                
                                        $45 $ $45 = x                   
                                                                                                         $ TransitChek Voucher Total
                   4.5% Processing Fee ( $ .045 ) x                                                                       
                           $18.00 Packaging and Delivery                                                                                       
                                               Total Order Cost ( $ )                                    +   +    
              
Order Form
                                        $50 $ $50 = x                   
                                                                                          $70 $ $70 = x
PRINT HERE TO ENSURE PROPER FORMATTING >>
Phone   Fax      
Email (Important: To receive order and shipping confirmation)        
           $45 ($48 in rides)   $ $45 =    x                                                   
                                        $55 $ $55 = x                   
                                        $75 $ $75 = x                   
                                                                                          $110 $ $110 = x
                                                                                          $125 $ $125 = x
                                                                                                                                    $150 $ $150 = x
                                                                                          $175 $ $175 = x
                                                                                          $200 $ $200 = x
Order Instructions
(for your records)
      
For questions about your order or assistance with ordering, call TransitCenter Customer Service at: 1.800.945.CHEK (2435).         Or visit us at www.transitcenter.com
Contact Name/Title          
* Required fields
                                        $100 $ $100 = x                   
  New mailing or email address provided?
ORDER INFORMATION       TransitChek is an IRS-approved commuter benefits program that lets employees save money on their commute by transit or eligible vanpools with tax-free dollars. They are eligible to use up to $230/month, tax-free. Please visit our website at: www.transitcenter.com for more information on using the TransitChek Program and other helpful information.
1. How to Order               How frequently do you plan to order:      2. Payment Options   3. Shipments All products will be received 7-10 business days after receipt of payment.     They will arrive in one box, via FedEx 2 Day service, and     Determine how many products you need to order per employee per benefit cycle. There is no minimum order.      Orders will not be processed until full payment is received. Please make checks payable to   "TransitCenter, Inc."   You may use a Certified Check, Bank Check, Money Order or Bank Transfer when placing your order. Sorry, no credit card orders at this time.       require a signature for delivery. 4. Fees Packaging and delivery fees for TransitChek orders are $18. Processing fees are 4.5% of your total order.
Order Frequency:  
PRODUCT RETURN POLICY    
BART High Value Ticket:                                  TransitChek® Vouchers: Can not be returned for credit or refund.                                               TransitChek® Card, a prepaid Visa® card: Cards have a one year expiration. Balances on TransitChek Cards that     Can not be returned for credit or refund. are near expiration or you suspect are damaged can be easily transferred to another TransitChek Card at www.transitcenter.com under Manage Your Account. Please remind your employees to review their current and unused products to make certain they are used before the expiration date. Can not be returned for credit or refund.
The TransitChek® Prepaid Visa® Card is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. The Bancorp Bank; Member FDIC.
SEND FORM & PAYMENT TO:    
Standard Deliveries:   Overnight Deliveries:      JPMorgan Chase
TransitCenter, Inc. General Post Office PO Box 27457 New York, NY 10087-7457 Attn: Lockbox 27457 4 Chase Metro Tech Ctr, 7th Fl. East Brooklyn, NY 11245 1-800-945-CHEK (2435)
                                                                                          $230 $ $230 = x