Bloomington Meals on Wheels, Inc

BLOOMINGTON MEALS ON WHEELS, INC. Volunteer Information

Name:______

Address:______

E-Mail Address:______Date of Birth:______

Telephone:______Cell Phone:______

Days Available to Deliver Meals: ___ Monday ___Tuesday ___Wednesday ___Thursday ___Friday

Would you be willing to drive in bad weather when needed? YES______NO______

Special Needs/Physical Limitations: ______

In addition to being assigned to a regular day route, would you be willing to drive occasionally when a substitute driver is needed? _____YES _____NO

Would you prefer to volunteer only as a substitute driver? _____YES _____NO

Have you ever been convicted for a felony? _____YES _____NO If yes, please explain:______

Current employer (if retired, last employer):______

Do you have a valid driver’s license? _____YES _____NO

Do you have a vehicle to use for meal delivery? _____YES _____NO

Does the vehicle meet minimum state insurance requirements? _____YES _____NO

Is your vehicle legally registered? _____YES ______STATE _____ NO

Have you had any moving traffic violations within the past five (5) years: __YES__NO If yes, please explain:______

The above statements are true and correct. SIGNATURE:______DATE:______