Fillable Driver Application and Agreement (King County OIRM)

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Driver Application and Agreement (King County OIRM)

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File type: PDF

U.S.A. forms for King County OIRM

BROWSE KING COUNTY OIRM (WA) FORMS

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1797 (09/17)
1. Name: ____________________________________________________________________________________________
First Middle Last Nickname
Have you ever participated in a Metro Rideshare program?
No Yes, (previous) name ______________________________________________________________________
2. Date of Birth: (Month/Day/Year) _________________________________________________________________________
3. Address:___________________________________________________________________________________________
Number Street Apt City ZIP
Mailing Address:____________________________________________________________________________________
(If different than residential address) Number Street / Apt / Box Number City ZIP
How long have you lived at this address? ________________________________
4. Contact e-mail: _____________________________________________________________________________________
Program Information will be communicated via e-mail.
5. Phone: Home: (_______)_________________________ Work: (_______)________________________ Ext. ____________
Cell: (_______)______________________________
6. How long have you had a driver’s license? Years______ Months ______
7. Do you currently have a valid and unrestricted Washington State Driver’s License? License #___________________________
If No, Explain: ______________________________________________________________________________________
8. Have you had a driver’s license in another State or Country within the past 5 years? Yes No
License #_____________________________________________ State or Country: ______________________________
9. Have you ever been convicted of driving while intoxicated or under the influence of drugs, or had your driver’s license or driving
privileges suspended, revoked or refused? Yes No
If Yes, Explain: ______________________________________________________________________________________
10. Do you have a condition that may or does result in physical or mental impairments: (For example, but not limited to, sight in
one eye, missing limbs, deafness, paralysis, convulsive or seizure disorder, epilepsy, blackouts, diabetes, heart disease, use of
driving aids, take medication or drugs, etc.). Yes No
If Yes, Explain: ______________________________________________________________________________________
11. Has an insurance company ever refused, cancelled, refused to renew, or given notice of intention to cancel or refuse any
automobile insurance to you? Yes No
If Yes, was your insurance: Cancelled? Refused? Not Renewed?
Name of Company: _______________________________________________________ Date: ______________________
Reason: ___________________________________________________________________________________________
12. Have you been required by any State to file evidence of Financial Responsibility (SR-22)? Yes No
If Yes, Explain: _____________________________________________________________________________________
Driver Application and Agreement
Office Use
Section 1: Driver Complete
PIN
GIN
Page 1 of 4
For which community or city are you applying to become a volunteer driver: ___________________________________________
1797 (06/17)
Accident #1
Date: Time of Day: a.m. p.m. Violation Type:
Who was at fault? Me Other Party Was there bodily injury? Yes No
Amount of damage to your vehicle: $ Amount of damage to other parties’ property: $
Details:
Accident #2
Date: Time of Day: a.m. p.m. Violation Type:
Who was at fault? Me Other Party Was there bodily injury? Yes No
Amount of damage to your vehicle: $ Amount of damage to other parties’ property: $
Details:
Name _____________________________________________________
13. As the driver of a motor vehicle, have you been involved in an accident in the past 3 years? Yes No
If so, describe any accidents below:
14. Describe all driving violations or citations (other than parking) for which you have been convicted, forfeited bail or paid any
fines during the past three years.
Violation #1
Date: Time of Day: a.m. p.m. City: State:
Violation or Conviction: If speeding: Legal limit mph Your speed mph Amount of fine $
Remarks
As a condition of participating in the King County Metro Community Van Program, your signature acknowledges agreement
to the attached King County Metro Community Van Program Terms and Conditions and authorizes King County to verify your
motor vehicle record history.
Signature __________________________________________________________ Date _____________________________
Please submit your application through email to: communityvan@kingcounty.gov
or provide a copy to your Community Transportation Coordinator.
Violation #2
Date: Time of Day: a.m. p.m. City: State:
Violation or Conviction: If speeding: Legal limit mph Your speed mph Amount of fine $
Remarks
Section 2: Driver Signature Required
Page 2 of 4
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1797 (09/17)
Section A: Driver
All Drivers in the King County Community Van Program agree that they are
21 years of age or older, attest that the information provided is complete
and accurate, have read and agree to comply with the Community Van
Manual, which may be found at: kingcounty.gov/communityvan/manual
and the following terms and conditions:
1. This Agreement shall be effective as of the date signed by the
Driver in Section 2. Drivers shall not be considered or hold
themselves out to be in the King County Community Van Program
until their applications have been approved by King County
Rideshare Operations. The Agreement shall continue in force
until one of the parties gives the other party written notice 15
calendar days prior to the planned date of termination. Drivers
may terminate their participation for any reason. King County may
terminate this Agreement for any of the following reasons:
A. if the operation of the Community Van becomes inconsistent
with the evaluation criteria established for the King County
Community Van Program
(kingcounty.gov/communityvan/manual)
B. if the Program in which the Driver is active is terminated;
C. if the Driver disrupts the operation of the Community Van;
D. if the Driver fails to abide by these Terms and Conditions;
or
E. for other reasons as determined by King County Rideshare
Operations.
2. A. Drivers acknowledge that King County may revise these Terms
and Conditions at any time without notice to the Drivers
and those Drivers shall comply with such revisions in order
to continue to participate in King County Community Van
Program.
B. Drivers will abide by the policies and rules set forth in the
King County Community Van Program Manual provided to all
Drivers by King County Rideshare Operations.
C. King County reserves the right to change or discontinue
any aspect of the King County Community Van Program,
temporarily or permanently, with or without notice to Drivers.
3. Drivers will indemnify and hold harmless King County, its
authorized agents, officials and employees from all claims, actions,
costs, damages or expenses of any nature whatsoever arising out
of or resulting from any delays, tardiness, and failure to make an
appropriate or scheduled pick-up, absence of the van or termination
of the Program.
4. Drivers acknowledge that King County Rideshare Operations
provides ridesharing services without screening the character or
background of Drivers or passengers. King County shall have no
responsibility or liability for any acts or omissions of King County
Community Van Program Drivers or passengers except as otherwise
provided in these Terms and Conditions.
5. Drivers agree that if they do not pay any amounts owed to King
County for their participation in the Community Van Program, King
County Rideshare Operations may refer the debt to a collection
agency in accordance with state and federal law.
6. King County prohibits the use of the King County Community Vans
to engage in any illegal, improper, actionable or criminal activity;
to violate any local, state, or federal statute, including but not
limited to threatening or harassing others; and to comply with all
applicable law.
7. King County is not responsible for any personal property lost or
damaged that may be associated with participation in the King
County Community Van Program.
8. Drivers understand that King County is a government entity and its
records related to the business of King County, including the King
County Community Van Program, are generally available for public
review. Driver’s personal information is subject to RCW 42.56.330.
9. These Terms and Conditions constitute the entire agreement
between each Driver and King County with respect to the
subject matter hereof and supersede all previous written or oral
agreements, if any, between you and King County with respect to
such subject matter. If Driver is any way dissatisfied with any of
these Terms and Conditions, Driver’s sole and exclusive remedy
is to discontinue participation in the King County Community Van
Program.
10. These terms of use shall be construed in accordance with the
laws of the State of Washington as well as with all federal law
and regulations, without regard to its conflict of law’s provisions.
You consent to the exclusive jurisdiction of the state and federal
courts in King County, Washington in all disputes arising out of or
related to these Terms and Conditions and the participation in the
King County Community Van Program. The invalidity of any term or
provision of these Terms and Conditions will not affect the validity
of any other term or provision. Waiver by King County of strict
performances of any provision of these terms will not be a waiver
of or prejudice King County’s right to require strict performance of
the same provision in the future or of any other provision of these
terms. No waiver by either party of any breach or default hereunder
shall be deemed to be a waiver of any preceding or subsequent
breach or default.
11. Drivers shall maintain valid driver’s licenses as required by the
State of Washington.
12. Drivers shall notify King County Rideshare Operations when they
no longer meet the Driver Selection Criteria established by the King
County Rideshare Operations http://metro.kingcounty.gov/tops/
van-car/pdf/LeadersPack.pdf info.
13. Drivers shall complete the King County Community Van Orientation
prior to taking possession of or operating vans.
14. Drivers shall drive vans to and from pre-planned destinations.
15. Drivers may assist with coordinating maintenance, cleaning
and servicing of vans with the assigned King County Rideshare
service Representative.
16.
Drivers
may be requested to keep daily and monthly records
as required by the King County Rideshare Operations,
submitting them to King County Rideshare Operations.
Terms and Conditions
Community Van
Program
Managed by King County Metro Rideshare Operations
KEEP THIS PAGE
Page 3 of 4
1. This Agreement shall be effective as of the date signed by the Driver
in Section 2. Drivers shall not be considered or hold themselves
out to be in the King County Community Van Program until their
applications have been approved by King County Rideshare
Operations. The Agreement shall continue in force until one of
the parties gives the other party written notice 15 calendar days
prior to the planned date of termination. Drivers may terminate
their participation for any reason. King County may terminate this
Agreement for any of the following reasons:
1797 (09/17)
17. Drivers may be required to report monthly odometer readings of
their van as required by the King County Rideshare Operations.
18.
Drivers shall coordinate with their T
ransportation Coordinator
to ensure continued operation of the van.
19.
Drivers agree they shall be considered to be volunteers under
the
law and shall not hold themselves out to be, or act as,
employees or agents of King County.
20.
Drivers shall at all times operate vans in a manner complementar
y
to the public nature of the King County Community Van Program,
keep the vans clean, drive in a courteous manner and, if asked,
explain the unique character of the use of the van.
21.
Operation of vans shall be restricted to King County approved
drivers.
22.
Safe driving habits and complete obser
vance of all traffic
regulations are required of all drivers. Any citation resulting
from the operation of a van is the responsibility of the driver
driving the van at the time of issuance of the citation. The
cost of any parking ticket, toll fines, and/or impound fees
resulting from improper parking or operation of the van is
the responsibility of the driver. All drivers shall report each
citation they receive for a moving traffic violation, whether
received while driving the van or any other motor vehicle, to
King County Rideshare Operations within 48 hours.
23.
Drivers shall promptly report any vehicular accident involving
bodily or property damage within 24 hours, whether the
accident occurred while driving the van or any other motor
vehicle, to King County Rideshare Operations as detailed in
the King County Community V
an Program Manual.
24.
Drivers shall ensure van is parked at the designated space
provided by the local jurisdiction or agency
.
25. Drivers shall not use vans for business purposes or for hire; to
pull trailers, boats, etc; to haul garbage, debris, or excessive
loads; for any purpose requiring the removal of seats; or for
any other purposes prohibited in the King County Community
Van Program Manual. Drivers acknowledge that they shall
have full liability and responsibility if vans are used for other
than permitted purposes or in a manner inconsistent with
these Terms and Conditions.
26.
Drivers shall drive vans only on hard sur
faced streets and
highways and other normal access roads and driveways.
Drivers shall not drive vans off-road, on beaches, in fields, or
in any other potentially unsafe environment.
27.
Drivers shall
not drive vans over bridges or roads posted for
less than a ton maximum weight load. Drivers shall observe
width and height clearance requirement of and for the van at
all times.
28.
Drivers shall not allow accessories, including window or
bumper stickers, appearance items or additional equipment, to
be added to or removed from the van without prior approval of
King County Rideshare Operations.
29. Drivers shall receive an orientation from the Transportation Coor-
dinator prior to operating the Community Van for the first time.
30.
Drivers agree to participate in program related sur
veys.
Section B: King County Rideshare Operations
King County Rideshare Operations agrees to comply with the following
Terms and Conditions:
1. King County Rideshare Operations shall provide vans for use by
Community Van.
2. King County Rideshare Operations shall provide for servicing and
maintenance of Community Van vehicles.
3. King County Rideshare Operations shall help drivers fulfill their
administrative obligations.
4. King County Rideshare Operations shall assist in maintaining
ridership.
5. King County Rideshare Operations shall provide service loaner vans
by reservation on a first come, first served basis.
6. King County Rideshare Operations shall ensure, to the best of
its ability, that no person shall be denied the opportunity to
participate in or be subjected to discrimination in the conduct of
the Community Van Program because of race, creed, color, sex, age,
national origin, sexual orientation, or the presence of any sensory,
mental or physical disability in any manner contrary to applicable
local ordinance, state or federal laws and regulations.
7. King County Rideshare Operations shall provide commuter groups
with an online Community Van Program Manual outlining policies
and rules applicable to the King County Community Van Program:
kingcounty.gov/communityvan/manual.
8. The King County Commuter Van Program, as a self-insurer under the
laws of the State of Washington, will provide payment of medical
and hospital bills up to $35,000 to any vanpool driver who sustains
bodily injury as a result of an occurrence while negligently operating
a van within the terms and conditions of a vanpool agreement with
that driver. These payments are only available for occurrences in
which no liability bond or policy or health insurance applies at the
time of the occurrence. Medical and hospital payments are for
reasonable and necessary medical expenses incurred as a result
of a covered occurrence and include payments for dental services,
prescriptions, prosthetic devices, ambulance expenses, and funeral
expenses. Medical payments do not include loss of income or
expenses for household services. This should not be interpreted as
personal injury protection (PIP) coverage.
Page 4 of 4
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Driver Application and Agreement (King County OIRM)

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Completed 18 July 2020

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