Your Name (required)

Your Email (required)

Date of Birth

Address

Home Phone

Work Phone

Cell Phone

Drivers License Number

License Restrictions

CPC Driving Policy: Drivers must be at least 25 years old and no more than 70 years old, with no more than 1 moving violation in the prior 3 years. Drivers with DUI or reckless driving infractions are ineligible to drive church vehicles.

Driving Record

Has you driver's license been ever been suspended, revoked or restricted?
YesNo

If yes, please provide details

Have you had a moving violation in the past 3 years?
YesNo

If yes, please provide details

Has any insurer cancelled your personal auto insurance policy?
YesNo

If yes, please provide details

Do you suffer from any physical impairment other than the use of corrective lenses?
YesNo

If yes, please provide details

Attach a copy of both side of your current valid driver's license to this application

I, the undersigned, certify that the information herein provided is true and complete to the best of my knowledge and that I have made no false, misleading or erroneous statements. I understand that this information will be provided to CPC's insurance carrier or to municipal authorities upon request. I have read the CPC policy on vehicle use (on reverse) and agree to abide with it. Subsequently, if I do not feel that I can carry out my driving responsibilities in a satisfactory manner, I will voluntarily notify CPC's Facility Manager to have my name removed from the CPC drivers list.

Electronic Signature