Senior Shuttle Volunteer Driver Application
Please take a few minutes to complete the information form below.

Personal Information

Name:
Date of Birth:
Address:
City: State: Zip:
Mailing Address if different than above:
Home Phone: Best Times to Call?
Work Phone: Best Times to Call?
Cell Phone:
E-mail:
Emergency Contact:
Phone:
Relationship to yourself:
Do you speak a language other than English? Other language:
Have you completed any Defensive Driving Classes? (for example: 55 Alive or AAA) Please state type of class and date completed:
How did you hear about our program?

Personal Character Reference

Name:
Address:
Home Phone: Work Phone:
Relationship
How long have they known you?

Days/Times Available

Please enter your availability below for the days of the week and the shifts you would be interested in driving.  We are extremely flexible – you drive as little or as often as you’d like, choosing the days and shifts that work for you.  Please remember, you are not committed to the days and shifts you indicate below.  As your schedule changes you may change your availability, even from one week to the next!  And if you are not available to drive for a week, or several weeks, or a month, or even several months, just let us know.
Please indicate your availability for morning shifts (8:00-12:30) or afternoon shifts (12:00-4:00) or both
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
How many shifts per week are you willing to provide?
Please describe any experience you have driving vans, motor homes, or 12-passenger vehicles:
Please note that such experience is NOT required for this position. Full training is provided at no cost.

Service Area

I am willing to serve persons who live in the following communities/geographic areas:
How familiar are you with this area?  Please describe your map reading abilities:

Driving Record

In the past 3 years, have you been involved as a driver in an automobile accident?  If yes, please explain:
Have you been convicted during the last 10 years of eluding a police vehicle, reckless (negligent) driving, vehicular assault/homicide, hit & run felony, more than one accident in a 3 year period, driving while intoxicated or under the influence of drugs?  If yes, please explain:

License Information

Drivers License Number: Expiration Date:
How long have you had a driver’s license?
Are there any restrictions on your license?   If restricted, state type and date of restriction:
Have you ever had your driver’s license suspended, revoked or refused?  If yes, please explain:
Has your insurance company ever refused, cancelled, non-renewed, or given notice of intention to non-renew automobile insurance to you?  If yes, please explain:

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