Add Driver Form - GSCSA Volunteer

Please complete this form in its entirety. All requested information should be reported EXACTLY as it appears on your driver's license.

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

If no, when will training be complete?*

date (MM/DD/YY)

How many years of driving experience does the driver have with this type of vehicle?*

Years

Name of Driver's Insurance Company:*

Policy Number:*

I warrant the above information is true and accurate to the best of my knowledge. I authorize any investigation of all statements herein and release the Girl Scout Council of the Southern Appalachians and it agents from liability in connections with any such investigation. I understand that untrue, misleading, or omitted information may result in dismissal, regardless of the time of discovery by the Girl Scout Council of the Southern Appalachians. Further, I authorize Palmer & Cay to review my Motor Vehicle Report and discuss with the carrier and/or its agents, representatives or MGA as necessary to determine my eligibility as a driver for the Council. I also give permission for the information to be discussed with the Council.

Signature*