uta=rideshare - Granite School District

UTA=RIDESHARE
UTA Vanpool Program
Vanpool Participant Agreement
Vanpool Request
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As a UTA Vanpool Participant, I am requesting to participate as (check all thot
T
Van
Part-time
Rider
Number:
T Full-time
Rider
T Bookkeeper T
Backup
Driver
r
Primary Driver
Group Point Of Contact:
Vanpool loin Date:
Participant Applicadon
Patticipsnt means all persoht including drivers, backup drieers, riders, and bookkeepen who ote transported to ond from work/school in o
Vqhpool operuted os port ofthe WA Vonpool Ptogrqm or ore otherwise authorized by UTA to porticipote ih the program.
Name:
Home Address:
Apt,
Ci,
State
ap Code
Mailing Address:
Apt"
City
s● te
ZIP Code
Phone Numbers:
Email Address:
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Employer Information:
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Emergency Contact:
Fun Name
As a
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condition of participating in the UTA Vanpool program administered by UTA, I agree to comply with the UTA Vanpool
Terms and Conditions, a copy oI which I have received. I understand and acknowledge that this Agreement, tagether with the
Vanpool Program Manual, estqblish my righ* and responsibilities os a porticipont in the UTA Vanpool Progrqm. As a Vanpool
participant, I understond that UTA will store my personal information in on electronic databose.* I certify that the above
information is true snd correct and agree to submit a new applicotion should ony of the information provided above chonge I
understand this Agreement sholl be effective on the date signed ond shall continue in force until either par| gives fifteen (15) doys
written notice of an intent to terminote, I understqnd that I must give written notice of teminotion to the group point of contact
and UTA Vanpool-
'The Vonpool Privaq Poliry is available online at http:/h,ttwr,t.utacommuter.com/.
Printed Name
Signature
PIcase ena″ ●rrax PandPa● Ol1 4ara“ ment
Emall to:
Date
YOur Vanpool Support Specialist
0R
Pholle:
(801〕
Fax to:
287‐ 2060
(801)287‐ 5031
utarldeshare@rldeuta com
Administrative
VCode:
MVR Requested:
Commuter ID #:
Rider Auth Sent:
Use
Only
Company Code:
Driver Auth. Sent:
Date Entered:
Remoyed:
urA=RTDEsHARE
UTAVanpool Program
Vanpool Participant Agreement
DriverApplicants Only
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Full Name as t Appears on Your Llcense
Date of Bi山
Yes「 No
Llcense Number
ksued Date 「 VJid and
ヽsuing State
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you have a large vehicle certification (L5 passenger capacity or
larger)? T Yes F No
Date:
Certification from:
2. Have you ever had an automobile license or privileges suspended, revoked or refused in the last 10
a.
years?
I-
Yes t- No
Ifyes, please explain:
3. Have you ever been convicted of driving while intoxicated or under the influence of
4. Do you have personal automobile
a. Name of
5. Have
insurance?
la
Yes t
drugs?
l-
Yes
l- No
No
Insurance Company:
you ever had an insurance company refuse, cancel, refuse to renew, or given notice of intention to cancel?
I- Yes
a.
l-: No
Ifyes, please explain:
6.Haveyoubeenrequiredbyanystatetofileevidenceof
a.
FinancialResponsibility(SR-22)? It Yes l-
No
Ifyes, please explain:
7. Indicate any driving convictions or citations fother t]ran parkingJ you have been convicted o[, forfeited bail or paid any
fines for during the past 3 years.
How many?
Please give
full details below. Additional remarks may be continued on a separate sheeL
$
Date
Time
Location: City, State
Conviction
Legal Speed
Limit
Your
Speed
Amount ofFine
Date
Time
Location: City, State
Conviction
Legal Speed
Limit
Your
Speed
Amount ofFine
Date
Time
Location: City, State
Conviction
Legal Speed
Limit
Your
Speed
Amount of Fine
$
b.
$
8. How many motor vehicle accidents of any kind or cause have you as an operator been involved in during the past
3
Please give full details below. Additional remarks may be continued on a separate sheet.
years?
l-YesTNo$
a.
Date
T
Yes
Bodily
t-
Time
Violation - Type
「
Yes「 No
tniury
Bodily
yourVehicle
t-YesrNo$
Dama8e to Other Property
Who was at fault
b.
Date
Damage to
Description:
No
Iniury
Location: City, State
Time
Loca●
on:City,State
Description:
Who was at fault
Violatlon‐
珈 e
TYesTNo$
f-YesTNo$
Damage to your Vehicle
Damage to Other Prope‖
y
UTAgRIDESHARE
UTA Vanpool Program
Vanpool Participant Agreement
safety ls a top prlorlty for UTA. Please conslder your personal health when applying to be a vanpool Driver.
I certily that I do not hove any medical conditions or toke ony medications thqt interlere with my obility to safely operote a
UTA Van. ln the event I develop o medical condition or begin taHng medicotion that inteteres with my obility to safely operate
q UTA Von, I ogree to immediatebl stop driving a Von until I cqn safely operote iL Examples of health conditions thot may
interfere with the ability to sqfeu operate a UTA Van include, but qre not limited to: vision problemg deafness, porolysis,
convulsions, seizure disorders, epilepry, loss of consciousness, diobetes, heqrt disease, etc. Exomples of disquolifying medication
include, but are not limited to, medications that contain prohibitions on driving.
I understqnd that qny elecaonic handheld device usoge while driving o UTA van is stridly prohibited.
I certily that the information I provided in the Driver Applicant portion of this Application is true and coTect and agree to
submit a new opplicotion should any of the information provided dbove change. I authorize UTA tn verily any information
provided herein. I agree that I will not hold myself out to be a Mmar! or Backup Driver in the UTA Vanpool Program until I
have received written dpproval by UTA Vanpool. As a condition of pdrticipating in the UTA Vanpool Progrom, I agree to comply
with the UTA Vanpool Terms and Conditions and the rules set lorth in the Vanpool Program Manual, copies of which I have
received.
Signature
Printed Name
Bookkeeper only
Only one (1) Bookkeeper per Vanpool group. Please verify with your Vonpool Group Point of Contact who is the Bookkeeper,
I have carefully reod, understand and agree to the l]TA Vanpool Progrqm Tems and Conditions Section B: Bookkeepers
agree to provlde accurate and timely information as required W the Terms and Conditions
PHnted Name
to:
Yourvanpool Support
Specialist Phonc:
oR
F.r to:
utandeshare@rideuta-com
Date
Slgnature
Please emall or Iox aU
Emall
I
Particirytion Agreements ond Driver Applicotions.
287-2060 Uall to: UTA Vanpool operations Physlcal Address;
(801)
(801)
287-5031
PO Box
30810
salt take city, uta}l
84130
No Mail Service
4384 s s0 w, Murray, utah 84107
rt●
C8030311