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Florida Annual Conference United Methodist Church - page 3 / 3

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Florida Annual Conference United Methodist Church

2007 Department for Ministry Protection

Church Trip Form

Driver #3:

Any Moving Violations in the Last Five Years:

  • Yes No (MVR Pulled

_________)

Driver’s Name:

( a s i t a p p e a r s o n D r i v e r s L i c e n s e ) D r i v e r s L i c e n s e N u m b e r :

(including state of issuance)

Date of Birth:

Signature of Driver

Date

Driver #4:

Any Moving Violations in the Last Five Years:

  • Yes No (MVR Pulled

_________)

Driver’s Name:

( a s i t a p p e a r s o n D r i v e r s L i c e n s e ) D r i v e r s L i c e n s e N u m b e r :

(including state of issuance)

Date of Birth:

Signature of Driver

Date

Please photocopy this form for additional drivers.

Keep this form for your records and fax a copy to the: AJG Risk Management Service Team at (561) 892-3982 or e-mail to: UMCFLA@ajg.com

Administered by: Arthur J. Gallagher Risk Management Services Arthur J. Gallagher & Co. (Florida) 2255 Glades Road Suite 400 E Boca Raton, FL 33431 Phone: (800) 282-8011 ext. 126 Fax: (561) 892-3982 Additional information and all forms are available on the Florida Conference website (www.flumc.org) Revision Date: 12/18/2006

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