Designated Driving Services
Release & Permission Form

I hereby waive, release and absolve Designated Driving Services and its offices, agents, employees, organizers, representatives, supporting establishments or sponsors, when acting in a capacity to represent Designated Driving Services from any and all loss, damage, liability, claim, suit or expense resulting from or in any way related to Designated Driving Services and/all above parties.

Please fill out Release & Permission Form. Your form will not be accepted if it's not completed! We will contact you by phone or by email to confirm your reservations.

Customers Information:

Name:

Address:

City: State: Zip: County:

Phone: E-mail:

Vehicle Make & Model:

License Plate:

Owner? Yes No, Owner's Name & Number

Insurance Company:

Policy Number: Expiration Date:

I, , give permission to DDS of Bucks & Montgomery Counties PA to operate the above listed vehicle when said request is made. DDS, drivers and vehicle operators are insured to operate this vehicle by the above stated owner's insurance policy. I have read and understand the terms stated on this document and agree to all said terms.

I, , further state that there are no contraband, weapons, illegal drugs or alcohol in my vehicle or on my person. Driver Initials .

Signature: Date:

Filled Out By DDS Staff Only:

Pickup Date:

Driver (s) Name: Club/Venue:

Pick-up Time: Drop-off time:

Ride To Or From:

Credit Card #: Exp Date:

Code: Visa MC AmExp Discover

Cost Of Ride: $

Best Time To Contact: AM PM