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2. Use the following form to begin your enrollment in PART’s XPass Employer Discount program. Once we receive your application we will verify your employment with your company. When your employment has been confirmed, you will receive an email with your XPass code. You will need the code when registering your Umo Mobile & Smartcard Ticketing account.

   
   

   *If you prefer to use the Umo Smartcard please indicate so below and a card will be mailed to the home address provided.

3. 
5. Prefix*
   -- Select One --Mr.Mrs.MissMs.Dr.Prof.Rev.
6. First Name*
7. Last Name*
9. Address*
   Street Address
11. City
12. State*
    -- Select One --Armed Forces AmericasArmed Forces EuropeArmed Forces PacificAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
13. Zip Code
15. Phone*
16. Email*
18. Company Name:*
    -- Select One --Ardmore Family PracticeBB&TBrenner's Children's HospitalCity of Winston SalemCML Microsystems Inc.Cone Health Alamance Regional Medical CenterCone Health MedCenter MebaneCone Health Moses H. Cone Memorial Hospital Cone Health Wesley Long Hospital Cone Health Women's Hospital Constangy, Brooks, Smith & PropheteCounty of ForsythCrisis Control MinistryDepartment of Veterans AffairsGreensboro News & RecordGoodwill Winston-SalemHousing Authority of Winston-SalemInmarNovant Health Forsyth Medical CenterReynolds AmericanTruliant Federal Credit UnionUnited Way of Forsyth CountyUniversity of North Carolina at Greensboro (UNCG)University of North Carolina at Chapel Hill (UNC) UNC Medical Center VetLawWake Forest Baptist Health Medical CenterWake Forest UniversityWells FargoWinston-Salem JournalWinston-Salem State University (WSSU)Womble Bond DickinsonMy company is not listed
20. Company Address*
    Street Address
22. City
23. State*
    -- Select One --Armed Forces AmericasArmed Forces EuropeArmed Forces PacificAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
24. Zip Code
26. Do you plan to use the Umo?

    1. Mobile Phone App
    2. Smart Card
28. Rules and Regulations

    I have read, understand, and agree to adhere to PART’s XPass Employer Discount program rules and regulations. I also understand I will be required to adhere to the rules and regulations of the Umo program upon completion of enrollment in the program.

29. XPass Employer Rules & Regulations
    Click to view rules and regulations
31. Please agree to the XPass Rules and Regulations

    1. I agree
    2. I do not agree
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field