Driver Evaluation

Current Driver Information
Scheduling Information

Complete this form to provide us with driver, contact and payment information (Visa, MasterCard, Discover and American Express cards are accepted).

PLEASE REMEMBER TO INFORM THE CLIENT THE FOLLOWING
By completing and submitting this Driving Evaluation form, including voluntarily disclosing information as it relates to your request for a driving evaluation, please be advised of AAAWCNY's Privacy Policy, accessible on AAA.com.

AAAWCNY vehicles used during driving evaluations may be equipped with video and/or audio recording devices. These recordings may be used for instructional, safety, quality assurance, or compliance purposes. Do you consent to the recording, and use, review, and retention of these recordings?

You understand that the evaluation does not constitute medical advice, a medical examination, diagnosis, treatment, or a determination of my physical or mental fitness to drive. AAA Western and Central New York is not a Certified Rehabilitation Specialist (“CRS”) as defined by the New York State Department of Motor Vehicles (“DMV”).

Driver Information

Driver First Name

Driver Middle Name

Driver Last Name

Driver Date of Birth

Driver Phone Number

Driver Street Address

Street Address

City/Town

State

Zip Code

Driver Email

Does the driver have any license or self restrictions?

Yes

What are the license or self restrictions?

Reason for the Evaluation

Court Ordered

DMV Required

Employment Required

Medical

Other

List Any Additional Reason for Evaluation

^$65/yr

INCLUDED BENEFITS:

^$105/yr

INCLUDED BENEFITS:

ALL AAA BASIC FEATURES, AND...

^$140/yr

INCLUDED BENEFITS:

ALL AAA PLUS FEATURES, AND...

^$65/yr

INCLUDED BENEFITS:

^$105/yr

INCLUDED BENEFITS:

ALL AAA BASIC FEATURES, AND...

^$140/yr

INCLUDED BENEFITS:

ALL AAA PLUS FEATURES, AND...