<p> BLOOMINGTON MEALS ON WHEELS, INC. Volunteer Information</p><p>Name:______</p><p>Address:______</p><p>E-Mail Address:______Date of Birth:______</p><p>Telephone:______Cell Phone:______</p><p>Days Available to Deliver Meals: ___ Monday ___Tuesday ___Wednesday ___Thursday ___Friday</p><p>Would you be willing to drive in bad weather when needed? YES______NO______</p><p>Special Needs/Physical Limitations: ______</p><p>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</p><p>Would you prefer to volunteer only as a substitute driver? _____YES _____NO</p><p>Have you ever been convicted for a felony? _____YES _____NO If yes, please explain:______</p><p>Current employer (if retired, last employer):______</p><p>Do you have a valid driver’s license? _____YES _____NO</p><p>Do you have a vehicle to use for meal delivery? _____YES _____NO</p><p>Does the vehicle meet minimum state insurance requirements? _____YES _____NO</p><p>Is your vehicle legally registered? _____YES ______STATE _____ NO</p><p>Have you had any moving traffic violations within the past five (5) years: __YES__NO If yes, please explain:______</p><p>The above statements are true and correct. SIGNATURE:______DATE:______</p>