Driver's Information

Responsible person

Full name

Email

Phone

Address

Attach a photo of driver’s license

Are you the primary Driver

Yes

No

If there is another driver, please submit the Driver's information by having the other driver(s) fill out this form.

In the past three years

Have you been at fault for any accidents?

Have you had any moving traffic violations?

Have you had any insurance company cancel or refuse to provide you with auto insurance?

Have you had your driver’s license revoked, suspended, or restricted?

Have you had any physical impairments other than corrective glasses?

If you marked any of the boxes above, please provide full details below: (dates, descriptions, amounts, or other explanation)

Details

Activity Information

Description of Event / Activity

Date of request

Day Request

Number of people Needing Transportation

Destination

Time, van will be picked up:

:

Time, van will be returned:

:

Agreement

I have read the conditions outlined on the Policy and Procedure for Church Vehicle Use and agree to abide by the same, and to make every effort to ensure that all drivers and passengers do likewise. All the information given in this form is true to this date.

Signature

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Vehicle Form

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Driver's Information

Activity Information

Agreement

Church Vehicle Usage Form