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2. JEFFERSON TRANSIT DRIVER APPLICATION
4. This application will be used to establish your eligibility as an operator of a public Vanpool group at Jefferson Transit. The information you provide helps us assure you, your Vanpool group, and the public that the highest standards of safety and accountability are maintained. We appreciate your cooperation and interest in our Vanpool program. Return completed application with a copy of your valid Driver’s License to your Vanpool Coordinator.
6. Vanpool #
8. Name
9. Date of Birth
   Date of Birth
11. Address
13. City
14. State
15. Zip Code
17. Phone Number
18. Work Number
19. Cell Number
21. Email Address
25. Current Job Title
26. Employer
28. Work Address
30. City
31. State
32. Zip Code
34. Supervisor’s Name
35. Supervisor’s Phone
37. Work Hours
38. Workdays (check)

    1. Mon
    2. Tue
    3. Wed
    4. Thu

    1. Fri
    2. Sat
    3. Sun
40. How long have you worked for this employer?
41. Years
42. Months
46. Do you have a current and valid driver’s license?

    1. Yes
    2. No
47. If not, please explain
49. How long have you had a driver’s license?
50. Years
51. Months
53. Driver’s license Number
54. Expiration Date
    Expiration Date
56. Are there any restrictions on your driver’s license?

    1. Yes
    2. No
57. If yes, state type (including vision) and date of restriction
59. Have you ever had your driving privileges suspended, revoked, or refused?

    1. Yes
    2. No
60. If yes, please explain
64. Has an insurance company ever refused, cancelled, not renewed, or given notice of intention to refuse automobile insurance to you?

    1. Yes
    2. No
66. If yes, list company’s and agent’s name and phone:
68. Indicate which (check one)

    1. Canceled

    1. Refused

    1. Non-Renewal
70. Date
    Date
71. Reason
75. Do you have any conditions that may affect your ability to perform all requirements of operating the Vanpool vehicle?

    1. Yes
    2. No
77. If yes, please explain
81. Have you ever been convicted of driving while intoxicated or under the influence of drugs?

    1. Yes
    2. No
83. If yes, please explain (date, charge, jurisdiction, etc.)
87. Indicate all driving violations or citations (other than parking) that you have been convicted of, forfeited bail, or paid any fines for during the past three years. Please give full details, including dates, below:
89. Section A
91. Date
    Date
92. Time
93. Location (City/State)
95. Conviction
96. If speeding, posted limit
97. Recorded Speed Cited for
99. Remarks
101. Section B
103. Date
     Date
104. Time
105. Location (City/State)
107. Conviction
108. If speeding, posted limit
109. Recorded Speed Cited for
111. Remarks
113. Accident #1
115. Date
     Date
116. Time
117. Driver
119. Violation
121. Who was at fault?
122. Damage to your vehicle?
123. Amount $
125. Bodily Injury?
126. Damage to your property?
127. Amount $
129. Description
131. Accident #2
133. Date
     Date
134. Time
135. Driver
137. Violation
139. Who was at fault?
140. Damage to your vehicle?
141. Amount $
143. Bodily Injury?
144. Damage to your property?
145. Amount $
147. Description
151. Can you provide off-street parking for the vehicle?

     1. Yes
     2. No
152. Ohter
154. By signing below, I understand that this application warrants a verification of information provided. Applications for Volunteer Driver authorize Jefferson Transit to obtain as often as desired my driving record, including all Department of Licensing actions that have taken place regarding the driver’s license I now hold, have held, or in the future may obtain.
156. This release continues in effect as long as I continue to serve as a volunteer driver on a Jefferson Transit Vanpool vehicle.
158. Signature
159. Date
     Date
Leave This Blank:


161. 1. Receive an email copy of this form.
162. Email address

     This field is not part of the form submission.

163. Submit

* indicates a required field