Driver Information Sheet

Please complete one sheet for each driver and one sheet for each private vehicle used.

Driver Information:
Name: Name: First Last
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Driver License Number:
Date of Expiration:
Date of Birth: Date of Birth: / MM / DD YYYY
Phone Number: Phone Number: - ### - ### ####
Private Vehicle Information (private vehicle used for church/institution purposes):
Name of Owner: Name of Owner: First Last
Address of Owner: Address of Owner:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Make/Model/Year of Vehicle:
License Plate Number:
Date of Expiration:
Insurance Information:

When using a privately owned vehicle, the insurance coverage is the limit of the insurance policy covering that specific vehicle.
*Please note that the minimal acceptable limits for privately owned vehicles is $100,000/$300,000
Insurance Company:
Policy Number:
Date of Policy Expiration:
Liability Limits of Policy:
Certification:

I certify that the information given on this form is true and correct to the best of my knowledge. I understand that I must be 21 years of age of older to drive on behalf of parishes, schools or other insured entities. I must be 25 years of age or older to transport minors. I must possess a valid drivers license, have the proper and current license and vehicle registration and have the required insurance coverage in effect on any vehicle used.

I also certify that I have completed the "Be Smart - Drive Safe" defensive driving course located on our Catholic Mutual risk management website: Phoenix.CMGConnect.org
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Driver Information Sheet

Driver Information Sheet

Driver Information:

Private Vehicle Information (private vehicle used for church/institution purposes):

Insurance Information:

Certification: