DRIVER F1RST/APP ACCOUNT REQUEST FORM
REQUIRED INFORMATION FOR DRIVER APP ACCESS
Full Name
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First Name
Last Name
Email Address
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Phone Number
*
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Area Code
Phone Number
Cell Phone Provider?
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Driver License Number
*
Driver License State
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Driver License Expiration
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Month
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Day
Year
Date
Insurance Provider
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Insurance Policy Number
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Insurance Expiration
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Month
-
Day
Year
Date
Many insurance policies have exclusions where if an insured party or vehicle is being driving commercial purposes, such as delivering food, then they may not pay your claim if you are deemed at fault. IT IS YOUR RESPONSIBILITY TO ENSURE YOU ARE AWARE OF YOUR INSURANCE POLICY EXCLUSIONS. PLEASE CONTACT YOUR INSURANCE AGENT OR REFER TO YOUR DECLARATIONS PAGE FOR ADDITIONAL INFORMATION.
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I UNDERSTAND
For IRS W-9: Please select if you are operating as an individual/sole proprietor, or as a Limited Liability Company
Individual/sole proprietor
Limited Liability Corporation
For IRS W-9: Please Enter your Social Security Number or your Employer Identification Number
*
IF YOU HAVE A PHOTO OF YOUR DRIVER LICENSE AND INSURANCE CARD, UPLOAD THEM HERE. IF NOT, TAKE A PHOTO AND E-MAIL TO STAFF@MYDELIVERME.COM AFTER SUBMITTING THIS FORM.
Signature for agreeing to Terms/Conditions:
Submit
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