Careers - Medical Transportation of America

Full Name

Address

Phone Number

Email Address

Are you legally authorized to work in the United States?

Yes No

Position Information

Position Applying For

NEMT Driver Dispatcher Other:

Employment Type

Full-Time Part-Time Contractor

Available Start Date

Hours Available

Driver & License Information

Driver’s License Number

State Issued

Expiration Date

Do you have a clean driving record (no major violations)?

Yes No

Have you ever had your license suspended or revoked?

Yes No

If yes, explain

Do you have experience transporting patients or passengers?

Yes No

If yes, how many years?

Previous Employment History (Past 10 Years)

Employer #1

Company Name

Address

Phone

Job TItle

Dates Employed: From

Dates Employed: To

Supervisor Name

Reason for Leaving

Employer #2

Company Name

Address

Phone

Job Title

Dates Employed: From

Dates Employed: to

Supervisor Name

Reason for Leaving

Employer #3

Company Name

Address

Phone

Job Title

Dates Employed: From

Dates Employed: To

Supervisor Name

Reason for Leaving

Professional References (Minimum 3 – No Family Members)

Reference #1

Name

Relationship

Company

Phone

Reference #2

Name

Relationship

Company

Phone

Reference #3

Name

Relationship

Company

Phone

Background Check & Drug Screening Consent

I understand that employment with Medical Transportation of America LLC may require a criminal background check, driving record check, and drug/alcohol screening. I consent to all required screenings as permitted by law.

Applicant Initials

Date

Authorization & Certification

I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in disqualification or termination of employment.

Applicant Signature

Date