Independent Driver Agreement

Please complete the form and click on the submit button when finished.

Date
Location
- Chronicle-Telegram
- Medina-Gazette
Position Applied For
- Motor Route
- Alternate Delivery
- Single Copy
Full Name*
FirstLast
Address*
Street AddressCityState / Province / RegionZip / Postal Code
Phone*
Email
By typing your name into the box below, I do hereby give my permission to The Chronicle-Telegram, their agent or representative to have a motor vehicle drivers record report made available of myself for the purpose of evaluation and consideration by The Chronicle-Telegram in engaging my service as an Independent Driver or outside solictor and not as an agent or employee of The Chronicle-Telegram.
I agree*
Driver's License Number*
How many violation points?
Do you have full use of a car for your work?*
- Yes
- No
**** If contracted, proof of automobile insurance is required ****