Commuter Van Program Application And Agreement Form
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4Commuter Van Program
Office Use Only
Application and Agreement
PIN
Section 1: All Applicants Complete
I am joining the:
Metro VanPool Program
Metro VanShare Program
Currently in program, update/change of information
I will be a (select all that apply):
Rider
Primary Driver
Backup Driver
Bookkeeper
If joining an existing group, list the: Vehicle Number (HOV) ____________________or Group Number (GIN) _____________________
If joining a newly forming group, list the Primary Driver/Group Coordinator name: __________________________________________
1. Name: __________________________________________________________________________________________________
Last
First
Middle
Nickname
Have you participated in the program under a different name?
No
Yes, previous name _____________________________
2. Address:_________________________________________________________________________________________________
Number
Street / Apt / Box Number
City
ZIP
3. Mailing Address: __________________________________________________________________________________________
If different than residential address
Number
Street / Apt / Box Number
City
ZIP
How long have you lived at this address? ______________________
4. Contact e-mail: ____________________________________________________________________________________________
Program Information will be communicated via e-mail.
5. Phone: Work (______) ____________________________ Ext. ___________ Home: (______) ____________________________
Cell: (______) ____________________________
6. Employer Name (or Contractor Name, if applicable):_______________________________________________________________
7. Work Site Name: __________________________________________________________________________________________
Work Site Address: ________________________________________________________________________________________
Number
Street / Apt / Box Number
City
ZIP
If you are applying to be a Driver, then complete Sections 2 and 3,
otherwise skip to Section 3.
Section 2: All Driver Applicants Complete
1. Date of Birth: Month _______________ Day _______________ Year _______________
2. Length of employment with current employer Years ________ Months ________ Job Title ________________________________
3. If less than 2 years, previous Employer Name: ______________________________________ Length of employment: __________
4. How long have you had a driver’s license? Years __________ Months __________
5. Do you currently have a valid and unrestricted Washington State Driver’s License? License # _______________________________
If No, Explain: _____________________________________________________________________________________________
6. Have you had a driver’s license in another State or Country within the past 5 years?
Yes
No
License #______________________________________________________ State or Country: ____________________________
7. Have you ever been convicted of driving while intoxicated or under the influence of drugs, or had your driver’s license or driving
privileges suspended, revoked or refused?
Yes
No
If Yes, Explain: ____________________________________________________________________________________________
8. Do you have a condition that may or does result in physical or mental impairments:
Yes
No (For example, but not limited
to, sight in one eye, missing limbs, deafness, paralysis, convulsive or seizure disorder, epilepsy, blackouts, diabetes, heart disease,
use of driving aids, take medication or drugs, etc.).
9. Has an insurance company ever refused, cancelled, refused to renew, or given notice of intention to cancel or refuse any
automobile insurance to you?
Yes
No
If Yes, was your insurance:
Cancelled?
Refused?
Not Renewed?
Name of Company: _________________________________________________________ Date: ___________________________
Reason: _________________________________________________________________________________________________
10. Have you been required by any State to file evidence of Financial Responsibility (SR-22)?
Yes
No
If Yes, Explain: ____________________________________________________________________________________________
1342 (Rev. 12/11)
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