Community Van/Special Use Volunteer Application & Agreement

Volunteer Application & Agreement

Thank you for your interest in participating in a Pierce Transit Community Van or Special Use program. Please provide the requested information in the fields below to get started.
Name*

First NameMiddle InitialLast Name
New programExisting program
DriverBookkeeper
What is the Group ID number?
Expected Start Date *

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred E-Mail*
example@example.com
Alternate E-Mail
example@example.com
Preferred Phone #*
Format: (000) 000-0000.
CellHomeWork
Alternate Phone #
Format: (000) 000-0000.
CellHomeWork
What company/agency are you affiliated with?*
Company/Agency Address*

Street Address

Building #

CityState

Zip Code
Company/Agency Phone #*
Format: (000) 000-0000.
DRIVING RECORD & INSURANCE

Information provided on your driver application and motor vehicle record will be used to determine your eligibility to drive a Pierce Transit vehicle.
Driver License Information
Add a photo of the FRONT of your current driver license.*

Browse Files
Attachments must be no larger than 5 MB. Cancelof
Add a photo of the BACK of your current driver license.*

Browse Files
Attachments must be no larger than 5 MB. Cancelof
Please provide your driver license number.*
Enter the expiration date on your driver license.*

MonthDayYear
Date of Birth*

MonthDayYear
Date
How many years have you had a driver license?*
NoYes
Please provide past license number.*
Select state of issuance. *
NoYes
Please list type and date of restriction(s).*
NoYes
Please provide date(s) and explanation.*
NoYes
Please explain.*
NoYes
Please explain.*
Insurance Information
Please provide the name of your automobile insurance company.*
Please list insurance expiration date.*

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

Browse Files
Attachments must be no larger than 5 MB. Cancelof
NoYes, cancelledYes, refusedYes, non-renewal
Reason for cancellation, refusal, or non-renewal.*
Driving History
NoYes
Please provide date(s) and explain. *
NoYes
Please provide citation details below.
Date*

MonthDayYear
Date citation was received.
Location (City and State)*
Citation *
Description of citation.*
NoYes
Please provide citation details below.
Date*

MonthDayYear
Date citation was received.
Location (City and State)*
Citation *
Description of citation.*
NoYes
Please provide accident details below.
Date*

MonthDayYear
Date of accident.
NoYes
NoYes
List approximate dollar amount of damage to your vehicle. *
List approximate dollar amount of any damage to other property.*
NoYes
Description of accident. *
NoYes
Please provide accident details below.
Date*

MonthDayYear
Date of accident.
NoYes
NoYes
List approximate dollar amount of damage to your vehicle. *
List approximate dollar amount of any damage to other property.*
NoYes
Description of accident. *
Acknowledgements
My signature below signifies that:
- I have received the Pierce Transit Community Van/Special Use Driver Requirements.
- I have read, understand, and agree to abide by all terms and conditions in the driver section of the Pierce Transit Community Van/Special Use Requirments.
- I understand my rights and responsibilities as a driver for a Community Van/Special Use program.
- 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 driver. (This release continues in effect as long as I continue to serve as a volunteer driver on a Pierce Transit vehicle.)
- I agree to allow Pierce Transit to review my Washington State Criminal History Background Check, as determined necessary by Pierce Transit.
- I agree to properly wear my seatbelt at all times. (Failure to do so may result in immediate revocation of driving privileges by Pierce Transit.)
- I agree to never use a cell phone or other telecommunication device while driving a Pierce Transit vehicle. (Failure to do so may result in immediate revocation of driving privileges by Pierce Transit.)
My signature below signifies that:
- I have received the Pierce Transit Community Van/Special Use Bookkeeper Requirements.
- I have read, understand, and agree to abide by all terms in the bookkeeper section of the Pierce Transit Community Van/Special Use Requirements.
- I agree to provide accurate and timely information as required by this agreement and outlined by Pierce Transit.
Signature*

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

MonthDayYear
Date
Should be Empty:

Volunteer Application & Agreement

DRIVING RECORD & INSURANCE