CONTACT – Valley Best Transportation

Name(Required)

Email(Required)

Phone(Required)

Pickup Address

Tell Us About Your Appointment

Type of Appointment

Destination Address

Type of Insurance

Do you need wheelchair assistance?

Yes

How many passengers will be traveling with you?

How many of your accompanying passengers are children?

Do you prefer a male or female driver?

Female

Male

No preference

Do you need an interpreter?

Yes

Language Preference

Notes & Special Requests

Do you have any special requests?

Notes about the appointment

Notes for the driver

Date

Date of birth

POSITION APPLIED FOR OR TYPE OF WORK DESIRED

Address

Street Address City State ZIP

TELEPHONE

SOCIAL SECURITY #

TYPE OF EMPLOYMENT DESIRED

FULL TIME

PART-TIME

TEMPORARY

DO YOU HAVE AN OBJECTION TO WORKING OVERTIME?

Yes

HAVE YOU EVER BEEN PREVIOUSLY EMPLOYED BY OUR ORGANIZATION?

Yes

HAVE YOU EVER BEEN CONVICTED OF A CRIME IN THE LAST 7 YEARS? IF YES, PLEASE EXPLAIN

Yes

CAN YOU SUBMIT PROOF OF LEGAL EMPLOYMENT AND AUTHORIZATION AND IDENTITY?

Yes

IF YES, PLEASE EXPLAIN (A CONVICTION WILL NOT AUTOMATICALLY BAR EMPLOYEMENT):

DRIVERS LICENCE NUMBER IF DRIVING IS AN ESSENTIAL JOB DUTY

ISSUE DATE

DATE OF EXPIRATION

HAVE YOU BEEN DRIVING FOR 60 CONSECUTIVE MONTHS?

Yes

HAVE YOU BEEN CONVICTED OF ANY MOVING VIOLATIONS WITHIN THE LAST 3 YEARS?

Yes

HOW WERE YOU REFERRED TO US?

EMPLOYMENT HISTORY

EMPLOYER NAME

POSITION HELD:

TELEPHONE

ADDRESS

IMMEDIATE SUPERVISOR

TITLE

DATES EMPLOYED

FROM:

TO:

JOB SUMMARY

REASON FOR LEAVING

OTHER SKILLS AND QUALIFICATIONS: SUMMARIZ ANY JOB-RELATED TRAINING, SKILLS, LICENSES, CERTIFICATES, AND/OR OTHER QUALIFICATIONS

EDUCATIONAL HISTORY

LIST SCHOOL NAME AND LOCATION, YEARS COMPLETED, COURSE OF STUDY, AND DEGREES EARNED

HIGH SCHOOL NAME

YEARS ATTENDED

LOCATION

DATE GRADUATED

COLLEGE NAME

YEAR OF GRADUATION

LOCATION

COURSE OF STUDY

I hereby authorize Valley Best Transportation to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from all liability Valley Best Transportation and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will or with or without cause, at any time, so long is there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I authorize Valley Best Transportation to conduct a full criminal background check, fingerprinting and drug screening. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant Signature:

Date:

REFERENCES

LIST 3 REFERENCES NAMES AND YEARS KNOWN. DO NOT INCLUDE RELATIVES OR EMPLOYERS

NAME

YEARS KNOW

TELEPHONE

RELATIONSHIP

NAME

YEARS KNOW

TELEPHONE

RELATIONSHIP

NAME

YEARS KNOW

TELEPHONE

RELATIONSHIP

Ask Staff Members for Our Medical Transportation Services

Valley Best Transportation

Your Contact Info

EMPLOYMENT HISTORY

DATES EMPLOYED

EDUCATIONAL HISTORY

REFERENCES