Van Driver Questionnaire

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All individuals who seek permission to drive the Derry Church van must complete and submit this form and read the Van Driver Policy approved by Session: https://www.derrypres.org/wp-content/uploads/2022/05/DPC-Vehicle-Policy-5-22.pdf

Email *

Name *

Address *

In what state(s) have you held a valid driver's license? *

Do you possess a current vehicle operator's license? *

Yes

Required

For all licenses that you have possessed within the last three years, list the state in which the license is registered as well as expiration date, license number, and your full name as it appears on the license. If you have another type of license (CDL, Chauffeur, etc) please explain below. *

Have you ever had an operator's license revoked or suspended? *

Yes

Required

If yes, explain:

List all moving violations and crashes you have had within the past 3 years. If none, write NONE *

Have you ever received a citation for driving while under the influence of alcohol, drugs, or other controlled substances? *

Yes

Required

If yes, explain:

Have you ever been required to attend an alcohol offender's school, traffic offender's school or other remedial traffic school required by the courts? *

Yes

Required

If yes, explain:

Have you ever completed a driver's education course? *

Yes

Required

If yes, list date below:

As a requirement to be approved as a church van driver, your motor vehicle report(s) will be obtained from the state(s) in which you have been licensed for the last 3 years, In order for Derry Church to access these records, you must call the church office and provide the church secretary with the last four digits of your Social Security Number AND your birth date. *

I understand and will call 717-533-9667

I will contact the PA Department of Transportation, obtain my driving record, and provide it to the church. I am responsible for the $12 fee.

I understand that all of the information provided on this form will be kept confidential. By typing in my name below, I certify that, to the best of my knowledge, the above information is correct. Further, I grant permission for my driving record to be obtained by a member of the Derry Presbyterian Church staff. *

Send me a copy of my responses.

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