DRIVER'S INFORMATION

Policy requires staff  provide Choice Health Care with the following information: [please initial]


__________     I have a valid Ohio Driver's License.  # ____________

__________     I have automible/driver's insurance.

                         Company:__________________________

                         Policy dates:________________________


______________________________                    _______________

Employee signature                                                   Date


______________________________                    ________________

Witness                                                                     Date