Johns Hopkins Hospital System

Commuter Request Form

Name(Required)

First Last

Personnel #(Required)

Work Ext(Required)

Request type:(Required)

Enrollment

Change

Termination

Organization:(Required)

Johns Hopkins Health System Corporation

The Johns Hopkins Hospital

Johns Hopkins Community Physicians

Select your pass for the bus, metro subway and light rail:(Required)

Regular – $77

Express – $93

Senior (65+) or Disability – $23

A picture ID is required when using a senior or disability pass.

Please check the box to authorize paycheck deductions. Note: Processing your application may take up to 30 days once received by Human Resources Central Office. Once your application has been processed, you will see the deduction on your paystub.(Required)

I authorize JHHSC/JHH to deduct the above amount from my paycheck. This authorization will remain in effect until I have canceled it in writing, at least 30 days prior to the effective to enroll and/or the cancellation date. I understand that passes are non-transferable. I will pick up my pass at the below location prior to the 9th day of the following month.

Please check the box to authorize termination.(Required)

I authorize JHHS to stop deducting the above amount from my paycheck. This authorization will remain in effect until I submit a request for deductions to resume.

Signature (enter your full name):(Required)