G6 Safe Drive Program Membership Request

G6 Safe Drive Program Membership Request

Provide your facility and contact details, then confirm your agreement to the program rules and policies.
Facility Name
Facility Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person Name

First NameLast Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I/we agree to follow the procedures set up by the G6 Program - Safe Ride. The G6 Program is for use by a veteran that has been flagged as intoxicated and unfit to operate a motor vehicle safely. Once flagged I/we agree that we will upload a gift certificate for Uber onto the veterans/facilities Uber App and input the Gift Certificate number provided by G6 Program. We will encourage the veteran into the rideshare and not allow them to operate a vehicle. G6 Program will provide four (4) Gift Certificate virtual numbers to the facility once approved and it's up to the facility to email/text G6 Program that more is needed.
Signature
Should be Empty: