Form_300-1_Driver_Application.pdf
PDF 159 KB Posted
- Attached to
- Caseload Management Software
- Solicitation number
- S-P22950-00006450
- Issued by
- Lake County, Albany City, Oregon
About this file
This is a driver application form for Ride Connection, an organization providing transportation services for older adults and people with disabilities in Oregon. The form serves as the initial screening document for both volunteer and paid drivers who will operate either agency vehicles, privately owned vehicles, or a combination thereof. Applicants must provide comprehensive personal identification information, including name, date of birth, address, phone number, and email address, along with details of all driver's licenses held within the past five years, including license numbers, issue dates, expiration dates, and any restrictions. The application requires disclosure of physical impairments, driving experience including experience with vehicles larger than standard passenger vehicles, and complete driving history documentation including any license suspensions or revocations, traffic violations, convictions, and accident involvement with specific dates, locations, and descriptions.
The application includes an insurance section for drivers using personally owned vehicles, requiring submission of insurance company information, policy numbers, and agent details. Applicants must provide a signed acknowledgement affirming good physical and mental health to safely operate motor vehicles, commitment to inform program management of any health changes or medications affecting driving ability, authorization for Ride Connection to conduct motor vehicle and criminal background checks, and consent to ongoing monitoring of motor vehicle records during their tenure as approved drivers. Applicants are permitted to attach supplementary documentation to support their qualifications for placement as drivers serving older adults and people with disabilities. The form was updated in 2017 and requires all information to be printed clearly for evaluation purposes.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
UPDATED 2017 FORM 300-1
Ride Connection Driver Application
(PLEASE PRINT ALL INFORMATION CLEARLY)
Provider/Agency: Driver Type: Volunteer Driver Paid Driver
Will driver be driving: Agency Vehicle Privately Owned Vehicle Combination
Driver Identification:
Name of Driver: Date of Birth:
Address:
Phone#:
Email address: _____________________________________________________________________________
Ride Connection will not sell or distribute your email address.
Please send me the Ride Connection newsletter.
Driver’s Licenses held within the last FIVE years:
State License Number Type or Class Original *
Issue Date
Expiration
Date
*Show original issue date if license is a renewal. If OR license was originally issued less than five years ago, please list previous license # and state of issue.
License Restriction? YES NO If yes, please describe:
Do you have any physical impairments? YES NO If yes, please describe:
Insurance: (For Drivers Using Their Own Vehicles)
Driver’s Insurance Company: Policy Number:
Name of Insurance Agent: Name of Insured:
Driving Experience:
How long have you had a driver’s license?
Do you have experience driving vehicles larger than a standard passenger vehicle? YES NO
If yes, please describe:
UPDATED 2017 FORM 300-1
Driving Record:
Has your driver’s license ever been suspended or revoked? YES NO
If yes, explain why, when and how long. Use an additional sheet if more space is needed.
Have you ever had any traffic violations or convictions? YES NO
Have you ever been involved in any accidents? YES NO
If yes, complete the following for each violation, conviction or accident:
Date City/State Description Type of Vehicle Fatalities/Injuries Fine, Penalty or Property Damage
Acknowledgement:
I am in good physical and mental health to safely operate a motor vehicle for the purpose of transporting Ride
Connection customers. If my physical or mental health changes I will immediately inform my program manager. If I am taking any medication, now or in the future, I will check with my pharmacist about the advisability of driving, and inform my program manager when appropriate.
The statements made and information given in this application are true. Ride Connection has my permission to obtain a motor vehicle and criminal background check. I understand that Ride Connection will monitor my motor vehicle record during my time as an approved Ride Connection driver.
Driver
Signature Date
NOTE: Please attach any additional information that you feel would be useful in determining your qualifications for placement as a driver for older adults and people with disabilities.
File details come from the government source that posted it. Updated .