Address:
street
city
state
zip NYS Driver's License #
VEHICLE: Vehicle to be used
by volunteer for ministry
Year:
Make: Model:
Do you own
vehicle::Yes
or No
INSURANCE: When
using a privately
owned vehicle, the insurance coverage is the linit of the insurance
policy covering
a spccific vehicle. Insurance
Company: Policy
#:
Date of Policy Expiration: Liability Limits of Policy:
List and describe serious accidents or
moving violations in the past five years.
I agree that I will not allow smoking when children/youth are
present in my vehicle. I agree that all
passengers in the vehicle must wear seat belts,
according to New York State Law.
CERTIFICATION
I certify that the information given on this form is true
and
correct of the best of my knowledge.
I understand that as a volunteer driver, I must be 21 years of age or
older, possess a valid driver's licence,
have the proper and current license and vehicle registration, and have
the required insurance coverage
in effect on any vehicle used to transport youth.
_________________________________
Date _____/______/______
Signature
(Please attach a
copy of your driver's license and insurance)