Vehicle Form

Read and fill out the form below

Charity Chapel Church Van Form

Driver's Information

This form must be filled out at least 30 days before the requested date.

Organization name (if applicable)

First and last name

Will you be the only driver?

Yes

No

Email address

Phone number

Address

Please attach a photo of your driver’s license here

Check any that are true that have occurred in the last three years:

Have you been at fault for any accidents?

Have you had any traffic violations?

Have you had any insurance company cancel or refuse to provide you with auto insurance?

Have you had your driver’s license revoked, suspended, or restricted?

Have you had any physical impairments other than corrective glasses?

None

If you marked any of the boxes above, please provide a complete and accurate description of the event below.

Incident details

Activity Information

Description of event or activity requiring transportation. If this event is recurring please specify this.

Date of request

Month

Day

Year

Number of people who will be transported

Destination

Start time

Time

HoursMinutes

End time

Time

HoursMinutes

Agreement

By typing my name below, I agree that I have read the conditions outlined on the Policy and Procedure for Church Vehicle Use. I agree to abide by those rules, and to make every effort to ensure that drivers and passengers do likewise. All the information given in this form is true to my knowledge.

Signature