NEMT Van driver Application

Lease Services Medical Van Driver Application

Please complete the entire application below and then click Send Application at the bottom of the page.

Your Information:
Name*
First Last
Cell Phone*
Home Phone*
Date of Birth*
MM slash DD slash YYYY
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Driver's License Information:
Do you have a valid Drivers License?*
If yes above what is the license #?*
Expiration Date*
MM slash DD slash YYYY
State of License Issuance*
Driving Experience:
Have you driven professionally in the past?
If yes for how long?
If you drove professionally in the past for what company?
Which Driving Opportunity are you interested in?*
If you responded "Other" above please explain
How did you hear about us?
To Be Read And Signed By Applicant
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquire of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at a decision. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connections with my application. I understand that false or misleading information given in my application may result in a negative decision to lease or drive a company vehicle. I understand, also, that I am required to abide by all rules and regulations of the Company.
Do you authorize Lease Services to run a background check?*
- Yes, I approve
- No
Enter Today's Date*
Authorized By (Please enter first & last name of applicant)*
Phone
This field is for validation purposes and should be left unchanged.

Lease Services Medical Van Driver Application

Your Information:

Driver's License Information:

Driving Experience:

To Be Read And Signed By Applicant