11 February 2021
Driver Form
Name of Driver:
Address:
Driver’s License #: _______________
State Issued: ________
Vehicle: _______________ Year _____________ Make____________________ Model:_________________Insurance Company’s Name: _____________________________
Liability Limits: (Minimum Limits of $100,000/$300,000 Required)
In order to provide for the safety of those we serve, we must ask each employee/volunteer to answer the following questions:
Answer True Or False
I have NOT had a conviction for an infraction involving drugs or alcohol
(such as driving under the influence or driving while intoxicated)
In the last three years.
I have NOT had two or more convictions for an infraction involving drugs or alcohol (such as driving under the influence or driving while intoxicated) in the last seven years.
I have had no more than three moving violations or accidents in the last three years.
Please be aware that when driving your own vehicle, your insurance is primary.
Thank you for helping us with our transportation needs.
Certification
I certify that the information given on this form is true and correct to the best of my knowledge. I understand driving for the Reach For The Stars, Inc. is a profound responsibility and I will exercise extreme care and due diligence while driving. I understand that as an employee/volunteer driver, I must be 21 years of age or older, possess a valid driver’s license, have the proper and current license and vehicle registration, and have the required insurance coverage in effect on any vehicle. I agree that I will refrain from using a cell phone or any other electronic device while operating my vehicle.
Volunteer Driver Signature: ________________________ Date: ________________
Approved by Board of Directors –