Volunteer Driver Application

Name*

First Middle Last

Home Address

Street Address City State ZIP Code

Contact Number*

Cell Number

Email*

Are you over 18 years old?

Yes

No

Third Choice

Social Security Number

Emergency Contact Person

First Last

Emergency Contact Phone Number

Driver's License Number

Expiration Date

Driver's License Class

Vehicle Description (Year, Make, Model)*

We 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.

Color

License Plate Numbers/Letters

REFERENCES

List

PLEASE LIST 3 REFERENCES (DO NOT LIST FAMILY OR RELATIVES) INCLUDE THEIR NAME, ADDRESS, PHONE NUMBER, HOW LONG AND HOW YOU KNOW THEM:

Name

Address

Phone

How long and how you know them

NO SMOKING POLICY

ASC 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 POLICY

1. 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 POLICY

PROFANITY, 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

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