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
I am joining a:*

New programExisting program
I will be a (select all that apply):*

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 #*
Phone Type*

CellHomeWork
Alternate Phone #
Phone Type

CellHomeWork
What company/agency are you affiliated with?*
Company/Agency Address*

Street Address

Building #

CityState

Zip Code
Company/Agency Phone #*
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?*
Have you had a different license number in the past five years?*

NoYes
Please provide past license number.*
Select state of issuance. *
Are there any current restrictions on your driver license?*

NoYes
Please list type and date of restriction(s).*
Has your driver license ever been suspended, revoked, refused, or placed on probationary status?*

NoYes
Please provide date(s) and explanation.*
Do you have a condition that may or does result in physical or mental impairments?*

NoYes
Please explain.*
Have you ever been required by the state to file evidence of Financial Responsibility (SR22)?*

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

NoYes, cancelledYes, refusedYes, 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?*

NoYes
Please provide date(s) and explain. *
Have you received any moving violations or citations (other than parking) in the past 3 years?*

NoYes
Please provide citation details below.
Date*

MonthDayYear
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?*

NoYes
Please provide citation details below.
Date*

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

NoYes
Please provide accident details below.
Date*

MonthDayYear
Date of accident.
Were you at fault?*

NoYes
Citation received?*

NoYes
List approximate dollar amount of damage to your vehicle. *
List approximate dollar amount of any damage to other property.*
Bodily injury?*

NoYes
Description of accident. *
Have you been involved in more than one auto accident in the past 5 years?*

NoYes
Please provide accident details below.
Date*

MonthDayYear
Date of accident.
Were you at fault?*

NoYes
Citation received?*

NoYes
List approximate dollar amount of damage to your vehicle. *
List approximate dollar amount of any damage to other property.*
Bodily injury?*

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