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ST. TIMOTHY CATHOLIC CHURCH

The Roman Catholic Diocese of Phoenix

Driver Information Form

Driver Information

Complete Name*

First Name

Initial

Last Name

Date of Birth*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

For which ministry are you driving?*

Best Phone*

E-mail address*

Driver's License Number*

State issued*

Expiration date*

Are you the registered owner of the vehicle?

Yes No

If you are not the registered owner, please fill in the name and address of the owner below.

IF YOU ARE NOT THE REGISTERED OWNER, PLEASE FILL IN THE NAME & ADDRESS OF THE OWNER BELOW

IF NOT THE OWNER - Full Name of Owner

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Vehicle Information

VEHICLE INFORMATION

Vehicle Owner's Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Vehicle License Plate Number*

State*

Expiration Date*

Make of Vehicle*

Model of Vehicle*

Year of Vehicle*

Using more than one vehicle?*

Yes No

VEHICLE INFORMATION (IF MORE THAN ONE VEHICLE BEING USED)

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Vehicle License Plate Number

State

Expiration Date

Make of Vehicle

Model of Vehicle

Year of Vehicle

Insurance Information

When using a privately owned vehicle, the insurance coverage is the limit of the insurance policy covering that specific vehicle. Please note that the minimum acceptable limits for privately owned vehicles are $100,000/$300,000.

Insurance Company*

Policy Number*

Date of Expiration*

Liability Limits of Policy*

10/20 15/30 50/100 100/300 250/500 300/500 Other

Please list liability limits

Please note: The minimum acceptable limits for privately owned vehicles are $100,000/$300,000.

Certification

I certify that the information given on this form is true and correct to the best of my knowledge. I understand that as a volunteer driver, I must be 21 years of age or older. I must be 25 years of age or older to transport minors. I must possess a valid driver's license, have the proper and current license and vehicle registration and have the required insurance coverage in effect on any vehicle used.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*