Volunteer Form

Agency*

Driver will be driving

First name*

Last name*

Birthdate*

Address*

License State*

License Number*

Issue Date*

Expiration Date*

Previous License State

Previous License Number

Do you have license restrictions?* No Yes

If yes, please describe the restrictions

Do you have physical impairments?* No Yes

If yes, please describe your impairments

Driver's Insurance Company

Name of Insurance Agent

Policy Number

Name of Insured

How long have you had a driver's license?*

Do you have experience driving vehicles larger than a standard passenger vehicle?* No Yes

If yes, please describe your experience

Has your driver's license ever been suspended or revoked?* No Yes

If yes, explain fully (why, when, how long, etc.).

Have you ever had any traffic violations or convictions?* No Yes

Have you ever been involved in any accidents?* No Yes

Acknowledgement

I am in good physical and mental health to safely operate a motor vehicle for the purpose of transporting Ride Connection customers. If my physical or mental health changes I will immediately inform my program manager. If I am taking any medication, now or in the future, I will check with my pharmacist about the advisability of driving, and inform my program manager when appropriate.

The statements made and information given in this application are true. Ride Connection has my permission to obtain a motor vehicle and criminal background check. I understand that Ride Connection will monitor my motor vehicle record during my time as a Ride Connection approved driver.

Please check this box if you agree with the above statement.*

Ride Connection exists because of your help!

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Got questions?

Give us a call: 503.226.0700
TTY: 711