SMP/CHOICES Annual Driver’s License and Insurance Coverage Certification Form
Will you or do you conduct outreach events and activities as a part of your Team Member role?
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Yes
No
Do you have a valid driver's license, insurance, and the ability to drive a vehicle?
*
Yes
No
Name
*
First Name
Last Name
Email
example@example.com
Program (select both if you are applying for/active in both programs)
*
CHOICES
SMP
Area Agency on Aging
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Agency on Aging of South Central CT
North Central Area Agency on Aging
Senior Resources Agency on Aging
Southwestern CT Agency on Aging
Western CT Agency on Aging
I understand, based upon my SMP/CHOICES Team Member role, I may be required to use my own vehicle in order to drive to and from events and other outreach activities. I certify that I have a valid driver’s license and current automobile insurance coverage. In the event that my automobile insurance policy or driver’s license lapses or changes, I agree to notify my SMP/CHOICES Coordinator immediately.
*
Submit
Should be Empty: