VTS Volunteer Driver Application

Main Office: 455 Court Street, Binghamton, NY 13904

Telephone: (607) 692-7669 ext. 205 Email: alexisVTS@rhnscny.org

What county do you reside in?

How did you learn about VTS?

Full Name*

First NameLast Name

Date of Birth*

Date

SSN*

Driver's License Number *

Driver's License Expiration Date*

Date

Upload your valid driver's license

Upload your vehicle registration

Upload your vehicle insurance card

Upload your NYS inspection sticker

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell phone number

Please enter a valid phone number.

Phone Number*

Please enter a valid phone number.

Android Smart PhoneApple Phone

Email address*

example@example.com

YesNo

Date

Violation

Result

Insurance Company*

Insurance Expiration Date*

Date

Vehicle Registration Expiration Date*

Date

Vehicle Make*

Vehicle Model*

Vehicle Year*

Upload Signed Backgound Authorization

Background Check Authorization Form

ATTESTATION STATEMENT:

Please read the following statement. I acknowledge I will be reimbursed for distance traveled from my home and back to my home while driving scheduled clients for the VTS. My automobile insurance will remain in effect; VTS’s insurance coverage is secondary. All requests for transportation will be screened and approved through the VTS. A Transportation Coordinator will contact you for specific dates and times. If accepted, you agree to abide by VTS guidelines, including completion of required vouchers indicating client and the miles driven. Vouchers will be provided by the VTS. The vouchers should be completed at the end of each run.

Please note the Volunteer Transportation Service does not discriminate. The eligibility of each driver is not based on age, race, color, or religious beliefs. Eligibility is based on the information provided by you as well as the references.

Signature (please sign in the box)*

Date*

Date

Traffic Violations

Convicted of Misdemeanor(s), Felony(s) or other crimes?

Availability

Vehicle Information

Background Check