Annual Renewal Declaration Form

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Advised staff about driver's license

The safety of our clients and drivers is vital. Driving safely requires excellent physical and cognitive skills, as well as good judgement. Unfortunately, various medical conditions or impairments beyond your control can negatively affect your driving, putting you and others at risk on the road. I will advise the staff of South Central Cancer Resource of any medical conditions or impairments that would negatively affect my driving, if my drivers licence is suspended or restricted for any reason, if I become the subject of any criminal investigation, if I become the subject of any child welfare investigations, or if any charges are brought against me, even if the charges are pending.

Please check the appropriate line:

There have been no occurrences as described above since my last Police Record Check or Renewal Declaration Form.

I confirm that my drivers licence and vehicle registration remain unchanged. Vehicle registration is at a minimum $2,000,000 liability ($5,000,000 preferred)

I hereby attest that the above statements are true, complete and accurate to the best of my knowledge and belief.

I hereby attest that the information disclosed herein is true, complete, and accurate to the best of my knowledge and belief.

Full Name*

Signature*