Volunteer Driver Application"*" indicates required fieldsStep 1 of 333%Name* First Middle Last Home Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Number*Cell Number*Email* Are you over 18 years old?* Yes No Third ChoiceSocial Security Number*Emergency Contact Person* First Last Emergency Contact Phone Number*Driver's License Number*Expiration Date* MM slash DD slash YYYY Driver's License Class*Vehicle InformationWe will ask for proof and take a copy of your motor vehicle insurance card. We need your insurance face sheet with the type of insurance and the amounts for liability/comprehensive/collision (by MN law you only have to carry liability). ASC’s excess automobile liability insurance becomes effective if you carry $50,000.Vehicle Year*Make*Model*Color*License Plate Numbers/Letters*Do you have experience driving for other programs or business?*Where would you be willing/comfortable driving?* In County Only Rochester Minneapolis/St. Paul Mankato Faribault Northfield AnywhereWhat days of the week are you able to drive?* Monday Tuesday Wednesday Thursday Friday Saturday SundayHave you ever been convicted of a felony?* Yes NoPlease explain*Have you had any accidents in the last 12 months?* Yes NoPlease date and give a brief explanation*Are you on any seizure medication*If you are on anticonvulsive medication, you are not eligible to be a volunteer driver for ASC. If once you are volunteering and the doctor prescribes an anticonvulsive medication or you have a seizure, you are to notify ASC and remove yourself from being a volunteer driver. Yes NoAre you on medication that would impair your driving ability?* Yes NoNO SMOKING POLICYASC HAS CHOSEN TO DEVELOP A “NO SMOKING” POLICY. THIS IS TO PROTECT BOTH THE ENVIRONMENT AND SAFETY OF OUR CLIENTS AND DRIVERS. PLEASE REFRAIN FROM SMOKING UNTIL OUT OF THE VEHICLE.VEHICLE POLICY1. VEHICLES SHOULD REMAIN CLEAN, CLEAR OF TRASH ON THE FLOOR AND SEATS.2. WINDOWS MUST BE KEPT CLEAN. CLEAN WINDOWS PROVIDE A CLEAR VIEW FOR SAFETY REASONS.3. ASHTRAYS SHOULD BE EMPTIED REGULARLY.4. NO LITTERING OUT OF WINDOWS.PROFANITY POLICYPROFANITY, SWEARING, RACIAL COMMENTS WILL NOT BE MADE OR TOLERATED BY ASC.Signature*MY SIGNATURE GUARANTEES THAT THE INFORMATION ABOVE IS TRUE, AND THAT I WILL USE MY PERSONAL AUTOMOBILE IN VOLUNTEER SERVICE. I WILL ARRANGE TO KEEP IN EFFECT MY AUTOMOBILE LIABILITY INSURANCE, NOTIFY ASC IF I HAVE A SEIZURE, DWI OR START TAKING ANTICONVULSIVE MEDICATION. LASTLY, I GIVE PERMISSION TO ASC TO CONDUCT A BACKGROUND CHECK. I WILL FOLLOW ALL THE POLICIES THAT ASC HAS STATED ABOVE.Date* MM slash DD slash YYYY CAPTCHAΔ
