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.