Vehicle Registration

Name:

First

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Please list each vehicle you may use to drive a client/rider: Vehicle #1 Make/Model/Year:

Please list each vehicle you may use to drive a client/rider: Vehicle #2 Make/Model/Year:

Please list the insurance company (s) covering your car(s):

Please check the following to continue:

I certify that I am currently insured through the above insurance company (attached copy of my insurance identification card) for automobile liability insurance in an amount in excess of or equal to the minimum required under Connecticut State law (minimum of $20,000 per person and $40,000 per accident for bodily injury liability and $10,000 per accident for property damage liability).
Further, I agree to forward a photocopy of my Proof of Insurance Card at each renewal period.
Further, I agree to immediately notify Rides For Ridgefield in the event that the above liability insurance is revoked, cancelled or altered in such a manner as to no longer meet the minimum vehicle insurance requirements for the State of Connecticut.
Further, I agree not to transport any passengers as part of the volunteer driver program if these minimums liability requirements are not met, or if my Connecticut vehicle operator’s license is not current and/or valid, or if the registration and license of the vehicle (s) I use to transport riders is not current and/or valid.
Further, I certify that my vehicle(s) is in safe operating condition and will be maintained in safe operating condition while I continue as a volunteer driver.

Signature

Clear Signature

Date Signed

VEHICLE REGISTRATION FORM