Commuter Van Program Application And Agreement Form Page 2
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4Name _____________________________________________________________
11. If requesting personal use of van, provide this information: Do you own a vehicle?
Yes
No
Name of Insurance Company:____________________________________________
Policy #:______________________________________________
12. When the van is parked at your home, can you provide off-street parking for the van?
Yes
No
13. As the driver of a motor vehicle, how many accidents of any kind have you been involved in in the past 3 years? ___________
Describe any accidents below:
Accident #1
Date:
Time of Day:
a.m. /
p.m.
Violation Type:
Who was at fault?
Me
Other Party
Was there bodily injury?
Yes
No
Amount of damage to your vehicle: $
Amount of damage to other parties property: $
Details:
Accident #2
Date:
Time of Day:
a.m. /
p.m.
Violation Type:
Who was at fault?
Me
Other Party
Was there bodily injury?
Yes
No
Amount of damage to your vehicle: $
Amount of damage to other parties property: $
Details:
14. Describe all driving violations or citations (other than parking) for which you have been convicted, forfeited bail or paid any fines,
during the past three years.
Violation #1
Date:
Time of Day:
a.m. /
p.m.
City:
State:
Violation or Conviction: If speeding:
Legal limit
mph
Your speed mph
Amount of fine $
Remarks
Violation #2
Date:
Time of Day:
a.m. /
p.m.
City:
State:
Violation or Conviction: If speeding:
Legal limit
mph
Your speed mph
Amount of fine $
Remarks
Section 3: All Applicants Complete – Signature Required
As a condition of participating in the King County Metro Commuter Van Program, the Participant agrees to
comply with the King County Metro Commuter Van Program Terms and Conditions, a copy of which the
Participant acknowledges receipt.
Signature________________________________________________________________ Date _______________________________
Your signature may warrant employment verification and/or a motor vehicle record history if this is also a Driver application.
King County Metro Rideshare Operations or Fax to: 206-684-2166
KSC-TR-0812
201 South Jackson Street
Seattle, WA 98104-3856
Page 2 of 4
1342 (Rev. 12/11)
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