PENDER UMC DRIVER’S DISCLOSURE AND AUTHORIZATION[1]
(Approved 09-11-09)
Printed Name of Applicant: _________________________________________________________
Date of Birth: ____________________________________________________________________
Residential Address: ______________________________________________________________
Driver’s License: _________________ State: ___________________________________________
Home Phone: ___________________________________________________________________
Mobile Phone: ___________________________________________________________________
Email Address: __________________________________________________________________
In order to assess your suitability to drive Pender UMC vehicles, and assess Pender’s liability as a result of permitting use of the church’s vehicles, the following information is needed to comply with Pender’s Vehicle Use Policy. This information will be used by Pender’s automobile insurance agent to check your driving record to confirm that your license is valid and in full effect.
1. Are you at least 21 years old? Yes ____ No ____
2. Do you currently hold a valid driver's license? Yes ____ (provide a photocopy with this form) No ____
3. Do you agree that you will notify the Church Administrator immediately if your driver’s license becomes suspended, restricted, or revoked? Yes ____ No ____
4. Do you agree that you will notify the Church Administrator immediately if your driver’s license number, legal name, or residential address changes? Yes ____ No ____
5. Do you give permission to Pender UMC to have the status of your license checked on an annual or as-needed basis? Yes ____ No ____
By signing below, you authorize Pender UMC’s automobile insurance agent, and/or its designee, permission to review your driving record as needed. Driving records will be checked.
Your signature certifies that the information set forth in this Disclosure and Authorization is current, accurate, and complete to the best of your knowledge, and you acknowledge that providing false, misleading, or materially incomplete statements will result denial or revocation of driving privileges. You also certify that you have been provided with, read, and agree to abide by all requirements of the current Pender Vehicle Use Policy.
Signature: _____________________________________ Date: ________________
You will be notified of authorization or denial to your request for driving privileges by the Church Administrator or authorized designee within approximately 5 business days of receipt of all information needed by Pender’s automobile insurance agent.
[1] For missionaries and representatives of mission organizations possessing only an international driver’s license, the status of their driver’s license cannot be checked by Pender’s automobile insurance agent. Approval of driving privileges will be granted based on written recommendation from the Church Council.
