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School Driver Registration Form

E 3541.10

KETCHIKAN GATEWAY BOROUGH SCHOOL DISTRICT
BUSINESS OFFICE
333 SCHOENBAR ROAD
KETCHIKAN, AK  99901

 

SCHOOL DRIVER REGISTRATION FORM

 

TYPE OF DRIVER (circle one):           Employee                    Parent                          Volunteer

NAME:______________________________________        DATE OF BIRTH:_________________________________________

ADDRESS:______________________________________  DRIVER LIC NUMBER:______________________________________

CITY/STATE/ZIP:______________________________________ EXP DATE:___________________________________________

HOME PHONE:____________________       WORK PHONE:____________________    CELL:______________________________

VEHICLE

REGISTERED OWNER:______________________________     YEAR:______________________________

ADDRESS:________________________________________   MAKE:______________________________

LICENSE NUMBER:_________________________________                                                              

SEATING CAPACITY:______________________________       SEAT BELTS:_______________________________

INSURANCE INFORMATION:

INSURANCE COMPANY:__________________________________________________________________________     

POLICY NUMBER:______________________________   EXP DATE:___________________________

Minimum acceptable liability limit for privately owned vehicles is $100,000 per occurrence.  If you transport students, it is recommended that your coverage be $300,000 per occurrence.  Attach copies of driver’s LICEnse, insurance card for the vehicle, and policy stating coverage,  to this form.

I certify that the information given above is true and correct.  I understand that if an accident occurs my insurance company shall bear primary responsibility for any losses or claims for damages:

 

Signature:________________________________________    Date:____________________

 

Fax to:  the School District Business Office at 907-247-2143 or mail to the address above.