Paid Drivers Form

Page 1

ITNAmerica and this organization respects your privacy. Personal information is used for aggregate reporting purposes only. We will not share your personal information with anyone else, without your express written permission.

Title:

First Name:

Last Name:

Suffix:

Address Line 1:

Address Line 2:

City:

State

Zip Code:

Is this your mailing address?

YesNo

Mailing Address (if different than street address)

Address Line 1:

City:

State

Zip Code:

Preferred Phone Type:

Mobile:

Home:

Work:

Email:

Alternate email:

Site info

SiteID

SiteName

SiteAddress

Site City

Site Phone #

Site Email

Page 3

Who should we contact in the event of an emergency?

Title

First Name

Last name

Suffix

Relationship

Street Address

City

State

Zip

Preferred Phone Type

Mobile

Home

Email Address

Page 6

Employment History (please list up to 3 past employers)

Employer #1 (current or most recent)

Company Name:

Address

Position Held:

Industry

Date From:

Date to: (or Present)

Manager/Supervisor:

Phone:

Reason for Leaving:

Employer #2

Company Name:

Address

Position Held:

Industry

Date From:

Date to: (or Present)

Manager/Supervisor:

Phone:

Reason for Leaving:

Employer #3

Company Name:

Address

Position Held:

Industry

Date From:

Date to: (or Present)

Manager/Supervisor:

Phone:

Reason for Leaving:

Page 7

ITN checks references to assure our customers that our volunteers have been thoroughly vetted for safety reasons.

Reference #1

Name:

Years Known

Address

Email:

Work Phone:

Mobile Phone:

Occupation:

How Acquainted:

Reference #2

Name:

Years Known

Address

Email:

Work Phone:

Mobile Phone:

Occupation:

How Acquainted:

Reference #3

Name:

Years Known

Address

Email:

Work Phone:

Mobile Phone:

Occupation:

How Acquainted:

Page 8

Driver Availability

If your application receives favorable consideration, when will you be available to begin work?

Can you work on Saturdays?

YesNo

Can you work on Sundays?

YesNo

Can you work early mornings (e.g., 5AM-7AM) ?

YesNo

Can you work at night ?

YesNo

Additional Availability info:

Page 9

The following information is needed If you will be using your vehicle to transport our customers. You may provide it now or during your training/orientation. To complete the form, you will need your registration and insurance information.

I am ready to provide my vehicle information.I will provide my vehicle information at the training/orientation session.

Vehicle information

Year:

Make:

Model:

Color:

# of doors:

# of seats

License Plate #:

Registration Exp.:

Insurance exp.:

Insurance Company:

Agent:

Phone:

Address:

Please describe the general condition of the vehicle and any known defects:

Are you the owner of this vehicle?

YesNo

Do you have a second vehicle that you would use to do volunteer driving

YesNo

Please provide the following information for the owner:

Name:

Phone:

Address:

Vehicle information

2Year:

2Make:

2Model:

2Color:

2# of doors:

2# of seats:

2License Plate #:

2Registration Exp.:

2Inspection exp.:

2Insurance Company:

2Agent:

2Phone:

2Address:

2Please describe the general condition of the vehicle and any known defects:

2Are you the owner of this second vehicle?

YesNo

Please provide the following information for the owner:

2Name:

2Phone:

2Address:

Page 10

"Organization" in this agreement refers to:

The facts set forth in my application for employment are true and complete to the best of my knowledge. The Organization may investigate all statements included in this application, and I understand that any false or misleading information provided during the application or interview process may result in withdrawal from consideration for employment or my discharge if I am hired, regardless of when discovered. I release from all liability all persons, companies, and corporations supplying this information. I also indemnify Organization against any liability which might result from making such an investigation.

I understand that this application is not a contract of employment. I also understand that if hired, regardless of any oral representation to the contrary, I will be an employee at-will and either I or Organization may terminate employment at any time for any reason with or without notice. Any changes in this relationship must be in a written document signed by the Organization.

By typing your name in the box below and submitting this form, you agree that your digital signature will be considered your legal signature and represents your agreement to the terms and policies outlined above.

Agreement Signature:

Agreement Date:

When you click Review and Submit below, you will be able to review your application before final submission. You must click Confirm on the Review page for your application to be complete.

AARP	Agency on Aging	Family member
Flier/Brochure	Friend	Health care professional
Internet	ITN customer	ITN staff/board member
ITN volunteer	Newspaper/Magazine	Place of Worship
Radio	Social worker	Speaker/Presentation
Television	Trade Show	Other
Employer

ITN Website	Online article/blog/white paper
Social Media – Facebook	Social Media – Twitter
Social Media - LinkedIn	Google (or other search engine)
Other

English	Spanish	Chinese	French
Japanese	Korean	Tagalog	Vietnamese

English	Spanish	Chinese	French
Japanese	Korean	Tagalog	Vietnamese

AAA	AARP
Elks	Junior League
Kiwanis	Knights of Columbus
Lions Club	Rotary
National Fraternity or Sorority