# Volunteer Driver Application Form

This form must be attached to a completed "Volunteer Worker's Application & Registration Form".

Driver Information

<div align="left" dir="ltr" id="bkmrk-driver-name%3A-date-of"><table><colgroup><col></col><col></col><col></col><col></col></colgroup><thead><tr><th scope="col">Driver Name:

</th><th scope="col">  
</th><th scope="col">Date of Birth:

</th><th scope="col">  
</th></tr></thead><tbody><tr><td>Position:

</td><td colspan="3">□ Staff □ Volunteer □ Intern □ VIP □ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

</td></tr><tr><td>Driver's Licence Number:

</td><td>  
</td><td>State:

</td><td>  
</td></tr><tr><td>Is your private vehicle being used?

</td><td colspan="3">□ Yes (complete the rest of this section)  
□ No (skip to next section)

</td></tr><tr><td>Vehicle Insurance Held With:

</td><td colspan="3">  
</td></tr><tr><td>Level of Vehicle Insurance:

</td><td colspan="3">□ Comprehensive  
□ Third Party Fire &amp; Theft/Third Party Only   
□ None

</td></tr><tr><td>Have you ever had Vehicle Insurance cancelled or denied?

</td><td colspan="3">□ No   
□ Yes, Reason: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

</td></tr></tbody></table>

</div>Motor Vehicle Accident History (Last 5 Years)

<div align="left" dir="ltr" id="bkmrk-year-of-accident-det"><table><colgroup><col width="134"></col><col width="506"></col></colgroup><thead><tr><th scope="col">Year of Accident

</th><th scope="col">Details of the Incident (Only note AT FAULT accidents):

</th></tr></thead><tbody><tr><td>  
</td><td>  
</td></tr><tr><td>  
</td><td>  
</td></tr><tr><td>  
</td><td>  
</td></tr></tbody></table>

</div>Traffic Infringements, Convictions, or Prosecutions (Last 5 Years)

<div align="left" dir="ltr" id="bkmrk-date-incurred-nature"><table><colgroup><col width="129"></col><col width="511"></col></colgroup><thead><tr><th scope="col">Date Incurred

</th><th scope="col">Nature of Infringement, Conviction, or Prosecution

</th></tr></thead><tbody><tr><td>  
</td><td>  
</td></tr><tr><td>  
</td><td>  
</td></tr></tbody></table>

</div>Licence Cancellation or Suspension

<div align="left" dir="ltr" id="bkmrk-date-incurred-reason"><table><colgroup><col width="127"></col><col width="310"></col><col width="202"></col></colgroup><thead><tr><th scope="col">Date Incurred

</th><th scope="col">Reason for Cancellation or Suspension

</th><th scope="col">Period of Time Enforced

</th></tr></thead><tbody><tr><td>  
</td><td>  
</td><td>  
</td></tr><tr><td>  
</td><td>  
</td><td>  
</td></tr></tbody></table>

</div>I confirm that the information I have supplied on this form is true and correct to the best of my knowledge. Should it be found the answers are untrue, I understand that may be grounds for dismissal from the position held.

Signed: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_

---

For Office Use Only:

<div align="left" dir="ltr" id="bkmrk-date-received%3A-proce"><table><colgroup><col width="101"></col><col width="124"></col><col width="117"></col><col width="300"></col></colgroup><thead><tr><th scope="col">Date Received:

</th><th scope="col">  
</th><th scope="col">Processed by:

</th><th scope="col">  
</th></tr></thead><tbody><tr><td>Outcome:

</td><td>□ Approved   
□ Not Approved

</td><td>Comments:

</td><td>  
</td></tr></tbody></table>

</div>---

This form should be kept on file along with a copy of the driver's current driver's licence.