Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Contact Phone Number
(###)
###
####
Cell Phone Number
(if different than your contact number)
(###)
###
####
Email
Are you planning to drive a personal vehicle?
*
Yes - I will provide the church office with a copy of my insurance card
No - I will only be driving the church van
Been at fault for any accidents?
*
Yes
No
If yes, please explain:
Had any moving traffic violations?
*
Yes
No
If yes, please explain:
Had any company cancel or refuse to provide personal auto insurance?
*
Yes
No
If yes, please explain:
Ever had a license revoked, suspended, or restricted?
*
Yes
No
If yes, please explain:
Been caught speeding more than 15 mph over the speed limit?
*
Yes
No
If yes, please explain:
Had any physical or visual impairment that cannot be corrected with glasses or contacts?
*
Yes
No
If yes, please explain:
During the past 5 years, have you ever been charged with or convicted of “driving while intoxicated” or “driving under the influence”?
*
Yes
No
If yes, please explain:
Are you under the age of 25 or over the age of 65?
*
Yes
No
Thank you! Please allow at least 10 days for the results. Please provide the church office with a photocopy of the front of your driver’s license.
Also, if you haven’t already done so, please fill out an Application for Volunteer Form (if you haven’t volunteered before) or the Renewal for Volunteer Form (if you have volunteered in the past)
