Volunteer Driver Registration Form
Thank you for your interest in making a difference in the lives of others
Date
*
-
Month
-
Day
Year
Date
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Driver's License Number
*
Driver's License Expiration Date
*
-
Month
-
Day
Year
Date
Vehicle Type
*
Make and Model
Color
Vehicle Plate Number
*
Insurance Company
*
Liability Coverage Limits per Person/per Accident
*
Please indicate when you may be able to drive
*
Monday
Tuesday
Wednesday
Thursday
Friday
Morning
Afternoon
In signing this document, I understand and agree to the following statements:
1. I hereby certify that the above information is accurate and complete to the best of my knowledge. 2. I hereby state that I am currently carrying Automobile Liability Insurance with a minimum coverage limit of $250,000 per person/$500,000 per accident. 3. I am aware that my automobile insurance is primary coverage. If I should be involved in an accident for which I am deemed at fault, my policy will be used first. If the policy limits are exhausted, then Help At Your Door’s insurance may cover the remaining loss. 4. I give permission to Help At Your Door to conduct a driving record check. 5. I am, to the best of my knowledge, free from any physical or medical condition which would impair my ability to drive safely.
*
Date
*
-
Month
-
Day
Year
Date
Email
Submit
Should be Empty: