Ready Rides Volunteer Application

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cellphone Number*

Format: (000) 000-0000.

Landline Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth*

Date

Type of the Vehicle*

Driver's License Number*

Insurance Provider*

Insurance Policy Number*

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

YesNo

lf yes, please explain:

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

YesNo

lf yes, please explain and list company agent name and phone:

Have you been convicted during the last 10 years of driving while intoxicated or under the influence of drugs?

YesNo

lf yes, please explain:

Have you had any moving violations or citations (other than parking) that you have been convicted of, forfeited bail, or paid any fines for during the past 3 years?

YesNo

lf yes, please explain:

The Questions below are just to let us know your preferences, none would affect the ability to volunteer:

Do you spend part of the year living in another location?

YesNO

If yes, what months are you gone?

Are you willing/able to: Transport passengers with medical equipment (e.g., an oxygen tank or walker)?

YesNo

Are you willing/able to: Transport a passenger with a seeing eye/service dog?

YesNo

Are you willing/able to: Have a passenger install an infant/child car seat in your vehicle?

YesNo

Are you willing/able to: Help a passenger carry groceries/packages to their door?

YesNo

This application warrants a criminal history background check, and verification of my motor vehicle record as authorized by my signature below. Forms will be provided at orientation.

My signature below authorizes Ready Rides to obtain, at its sole discretion and expense, my employment and non-employment driving record, including all Department of Safety actions that have taken place regarding the driver's license I now hold, have held, or in the future may obtain. It also authorizes Ready Rides to conduct the following checks: criminal history, sex offender status, NH BEAS. I further agree to any other conditions described herein. This release continues in effect as long as I continue to serve as a Ready Rides volunteer.

By signing this application form, I accept the following requirements of the aggreement:1. The information about driver's license is valid. 2. My vehicle is fully insured. 3. I accept all the responsibilities for injury, damage and traffic violations.

Signature*

Emergency Contact information for you:

Name:

Address:

Cellphone or landline:

Email:

Ready Rides Volunteer Application

Volunteer Driver Information

A positive response to the following four questions will not necessarily preclude you from volunteering.