NEMT Driver Job Application


Personal Info

First Name: *
Last Name: *
Email: *
Mobile: *
Date of birth: *
State and DL No: *
SSN: *
Authorized to work in the US:

Address Information

Street: *
City: *
State/Province: *
Zip/Postal Code: *


Current Title: *
Type of driving Experience:
Experience in Years:
Do you have any experience driving a passenger van: *
Physical capacity to push a wheelchair: *
Experience transporting disabled: *
Are you willing to take a drug test: *
Work History: *
Where you last worked, a telnumber to call for reference, your position and time in that position
Skill Set:
Level of Education: *
Reference 1 - Name of company/contact/tel number: *
Reference 2 - Name of company/contact/tel number:

Mandatory certifications

First aid and CPR certification:

Additional certifications

Defensive driving:
PASS Certification:
Wheelchair securement training:

Terms of Service

By checking this box, I certify that my answers are true and complete to the best of my knowledge. Nothing on this application is intended to create or imply a contractual relationship. If hired, the employee understands that employment is at will, in other words, that it is not for any specific time period or duration and can be terminated with or without reason at any time. While employment policies or procedures may change from time to time, only a written agreement signed by the company’s president can change the employee’s at-will status.

I understand that consideration for employment is conditioned upon the results of a clean driving record, a reference and background check. I attest to the accuracy and truthfulness of the information provided in this application and I understand that any misstatement of material facts will be grounds for disqualifying me from further consideration in the selection process, or if hired, grounds for discharge.
I also understand that as a condition of my employment, I must complete a drug and alcohol screening and have negative drug testing and alcohol testing results to be hired by Quick Staffing. I further understand that I will be given a physical exam to test for my physical ability to perform the job in question. I authorize Quick Staffing or its contracted facility to perform this test, and I understand that employment is contingent upon the results.
I understand that as a condition of my employment, a criminal background check will also be conducted. I will be given the opportunity to explain anything found in this check. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Attachment Information

Resume: *
First aid and CPR:
PASS certificate:
Driver's License:
Other certificates: