Rideshare Registration Number: 
First Name:
Middle Name:
Last Name:
Home Address:
Apartment Number:
City: State:  Zip:
Mailing Address:
City: State: Zip:
Home Phone:
Work Phone: Extension:
Cell Phone:
Email Address:
Date of Birth:

Employment Information

Employer:
Job Title:
Employer Address: Suite:
City: State: Zip:

Emergency Contact Information

First Name:
Last Name:
Relation to You:
Address: 
Apartment Number:
City: State: Zip:
Phone: 1 2

Driving History

License Number: State:
Expiration Date: Total Years Driving:
Previous License if current license held less than 3 years:
Previous State of License: Previous License Number:
Has your License ever been suspended or revoked?   Yes        No

Insurance

A copy of your proof of insurance will be required at the SCOOT Orientation!

Insurance Provider: 
Policy Number: 

Driving Record
Kitsap Transit will periodically review your driving record.

Number of moving violation in the past 3 years?
Number of accidents in the past 3 years?

By submitting this application, I certify that everything on this application is true. I authorize Kitsap Transit to check my driving record. I agree to all the rules and regulations of the SCOOT car program.  Click here to read SCOOT Rules and Regulations.