Vanpool Application & Agreement

Vanpool Application & Agreement

Thank you for your interest in vanpooling with Pierce Transit. Please provide the requested information in the fields below to get started.
Name *

First Name Middle Initial Last Name
I will be a (select all that apply): *

Rider Primary driver Backup driver Bookkeeper Backup bookkeeper
Will you be a full-time or part-time rider? *
Full-time riders pay a monthly fare and part-time riders pay a daily fare. If you plan to vanpool more than a few days a month, being a full-time rider is more cost effective. Monthly and daily fares are billed on the same monthly billing cycle. Refunds will not be issued for nonuse.
What day(s) of the week will you be vanpooling? Select all that apply. *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What week(s) of the month will you be vanpooling? Select all that apply. *

Week 1 Week 2 Week 3 Week 4 Week 5
I am joining a: *

New group Existing group
Please select the month you plan to start: *
Anticipated Start Date *

First of the Month (Around the 1st) Mid-Month (Around the 15th)
Anticipated Start Date *

Month Day Year
Who is the primary driver for your group? *

First Name Last Name
Group ID Number
Van #
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Preferred E-Mail *
example@example.com
Alternate E-Mail
example@example.com
Preferred Phone # *
Phone Type *

Cell Home Work
Alternate Phone #
Phone Type

Cell Home Work
Employer Name *
Employer Address *

Street Address

Building #

City State

Zip Code
Do you have an employer-provided ORCA card?

Yes No
Please upload a photo of your ORCA card here. *

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Please provide your ORCA card number. *
ORCA Card Number
How did you hear about us? *
Please tell us who referred you to Pierce Transit vanpool. *

First Name Last Name
VANPOOL DRIVER APPLICATION

Information provided on your driver application and motor vehicle record will be used to determine your eligibility to become a Pierce Transit vanpool driver.
Have you ever driven a vanpool before? *

No Yes
Which agency did you vanpool with? *
When did you drive? *
How long did you drive? *
Can you provide off-street parking for the van at your home? *

No Yes
Add a photo of the FRONT of your current driver license. *

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Add a photo of the BACK of your current driver license. *

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Please provide your driver license number. *
Enter the expiration date on your driver license. *

Month Day Year
Date of Birth *

Month Day Year
Date
How many years have you had a driver license? *
Have you had a different license number in the past five years? *

No Yes
Please provide past license number. *
Select state of issuance. *
Are there any current restrictions on your driver license? *

No Yes
Please list type and date of restriction(s). *
Has your driver license ever been suspended, revoked, refused, or placed on probationary status? *

No Yes
Please provide date(s) and explanation. *
Do you have a condition that may or does result in physical or mental impairments? *

No Yes
Please explain. *
Have you ever been required by the state to file evidence of Financial Responsibility (SR22)? *

No Yes
Please explain. *
Insurance Information
Please provide the name of your automobile insurance company. *
Please list insurance expiration date. *

Month Day Year
Add a photo of your current proof of insurance card, showing your name and dates insured. *

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Has an insurance company ever refused, cancelled, non-renewed, or given notice of intention to non-renew automobile insurance to you? *

No Yes, cancelled Yes, refused Yes, non-renewal
Reason for cancellation, refusal, or non-renewal. *
Driving History
Have you been charged with driving while intoxicated or under the influence of drugs in the past 10 years? *

No Yes
Please provide date(s) and explain. *
Have you received any moving violations or citations (other than parking) in the past 3 years? *

No Yes
Please provide citation details below.
Date *

Month Day Year
Date citation was received.
Location (City and State) *
Citation *
Description of citation. *
Have you received more than one moving violation or citation (other than parking) in the past 3 years? *

No Yes
Please provide citation details below.
Date *

Month Day Year
Date citation was received.
Location (City and State) *
Citation *
Description of citation. *
Have you been involved in an accident in the last 5 years? *

No Yes
Please provide accident details below.
Date *

Month Day Year
Date of accident.
Were you at fault? *

No Yes
Citation received? *

No Yes
List approximate dollar amount of damage to your vehicle. *
List approximate dollar amount of any damage to other property. *
Bodily injury? *

No Yes
Description of accident. *
Have you been involved in more than one auto accident in the past 5 years? *

No Yes
Please provide accident details below.
Date *

Month Day Year
Date of accident.
Were you at fault? *

No Yes
Citation received? *

No Yes
List approximate dollar amount of damage to your vehicle. *
List approximate dollar amount of any damage to other property. *
Bodily injury? *

No Yes
Description of accident. *
Acknowledgements
My signature below signifies that:
- I have received the Pierce Transit Vanpool Participant Agreement - Terms and Conditons.
- I have read, understand, and agree to abide by all terms of the Agreement.
- I understand my rights and responsibilities as a Vanpool Participant.
- I agree to properly wear my seatbelt at all times. (Failure to do so may result in immediate revocation of riding privileges by Pierce Transit.)
Drivers
- I agree to allow Pierce Transit to obtain a copy of my motor vehicle record and monitor for accidents, citations or suspensions during my time as a volunteer vanpool driver. (This release continues in effect as long as I continue to serve as a volunteer driver on a Pierce Transit Vanpool.)
- I agree to never use a cell phone or other telecommunication device while driving a Pierce Transit Agency vehicle.
Bookkeepers
- I have read, understand, and agree to abide by all terms in the Bookkeeper Section of the Pierce Transit Vanpool Participant Agreement - Terms and Conditions.
- I agree to provide accurate and timely information as required by this agreement and outlined by Pierce Transit Vanpool.
Signature *

Your application will not be accepted without a signature. Clear
Date

Month Day Year
Date
Should be Empty:

Vanpool Application & Agreement

VANPOOL DRIVER APPLICATION