Add Driver/Driving Record Request Form

Add Driver/Driving Record Request Form
Those adults who regularly drive council-owned vehicles, individuals who receive reimbursement for mileage for their own vehicle, and persons who have driving duties as a part of their volunteer assignment, should complete this form. Individuals must wait for approval after submitting this form before driving.

This check is valid for one year and will need to be reviewed annually. If for any reason your request is denied, you may submit another request at any time if any of your circumstances listed below have changed.
I have reviewed and accept the Guidelines for Drivers and acknowledge the Decision grid above. I am aware of the overall driving safety checkpoints found in the Safety Activity Checkpoints which can be found here.
Approved Driver Requirements
As a reminder, the following are required for an approved driver:

1. No citations for reckless driving or convictions for DUI/DWI during the last THREE (3) years.

2. If an individual has more than 1 conviction for DUI/DWI, they are permanently restricted from driving for Girl Scouts.

3. No individual with less than 5 years of driving experience and under the age of 21 will be allowed to transport girls.

4. Driver's license must be from the state of IL unless driver has lived in IL for less than 90 days.
Driver is a:*
Troop Number(s)*
Name (as it appears on Driver's License)*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Years of Driving Experience*
Drivers License Number*
Expiration Date*

MonthDayYear
State*

Street Address

Street Address Line 2

City

Zip Code
License Class*
https://illinoiscarlaws.com/driver-license-classifications/
Name of Driver's Auto Insurance Company*
Policy Number*
Driver experience information: Answer ALL questions. Use "0" or "N/A" if necessary. Persons not providing driver's experience information cannot be approved to drive.
1. Do you have a driver's license issued by the state of Illinois?*

YesNo
1a. Have you lived in Illinois for longer than 90 days?*

YesNo
Please do not continue this form. A valid Illinois license is required after 90 days of residency in the state of Illinois. Please return to this form when you have acquired an Illinois driver's license.
Please plan to provide an updated Illinois driver's license after 90 days of residency.
retired: Have you been licensed for less than three years in the current state (selected above)?*

YesNo
retired: If yes, in which state were you most recently licensed:*

Street Address

Street Address Line 2

City

Zip Code
retired: Name on prior state's license:

First NameMiddle NameLast NameSuffix
2. Are you licensed for and familiar with the type of vehicle to be driven?*

YesNo
Please do not continue this form. You must be licensed for and familiar with the type of vehicle to be driven. Please return to this form when the appropriate license is obtained.
retired: 2a. If no, when will training be complete?

MonthDayYear
Date
3. How many years of driving experience do you have with this type of vehicle?*

0-4 years5 or more years
Please do not continue this form. You must have 5 or more years of driving experience on this type of vehicle. Please return to this form when your experience is 5 or more years.
4. How many at-fault accidents have you had in the past three years?*

0-123 or more
Please do not continue this form. You must have fewer than 3 at-fault accidents in the past three years.
5. How many moving violations have you had in the past three years?

0-23 or more
Please do not continue this form. You must have fewer than 3 moving violations in the past three years.
6. Has your license ever been suspended?*

YesNo
7. Have you ever been convicted of a DUI/DWI or reckless driving?*

YesNo
7a. If yes, what is the conviction date?*

MonthDayYear
Date
8. Explain any accidents, violations, suspensions, including dates.*
Copy of Driver's License*

Cancelof
Please attach the policy declaration page(s) from your current auto insurance policy*

Cancelof
I warrant the above information is true and accurate to the best of my knowledge. I authorize any investigation of all statements herein and release the above named Girl Scout Council and its agents from liability in connections with any such investigation. I understand that untrue, misleading, or omitted information may result in dismissal, regardless of the time of discovery by the above named Girl Scout Council. Further, I authorize Palmer & Cay to review my Motor Vehicle Report and discuss with the carrier and/or its agents, representatives or MGA as necessary to determine my eligibility as a driver for the Council. I also give permission for the information to be discussed with the Council.
Signature of Driver*

Clear
Date*

MonthDayYear
Should be Empty:

Add Driver/Driving Record Request Form

Approved Driver Requirements