Individual Contractors or Service Providers – Apply Online

First Name *

Middle Name

Last Name *

Phone Number *

DOB

EIN Number

Contact Email *

Location *

Current Address

Home Address

City *

State *

Zipcode *

How long have you been at your present address?

Previous Address

City *

State *

Zipcode *

Education

Years of formal education completed:

Grade School

High School

College

Work History

Currently Employed?

Yes

Self-Employed

List all employers for the past 5 years, dates of employment and reasons for leaving:

Driving Experience & Information

Number of years’ experience as a professional driver:

Car

Truck

Wheelchair Van

License now held, please check all that are applicable:

Class A

Class B

Class C

Driver’s License Number

Expires

Commercial Driver’s License Number (CDL)

Expires

Are you willing to attend driver training courses? *

Yes

Are you willing to do a pre-employment background and drug screen? *

Yes

Do you consent to us doing a criminal background check? *

Yes

Do you consent to us performing a motor vehicle check? *

Yes

Are you willing to display our Company signage in your vehicle? *

Yes

Are you willing to allow the Company or any regulatory body agency overseeing this line of work inspect your equipment (to include personal or company vehicles)? *

Yes

Driver Qualifications

Are you 24 years of Age or older? *

Yes

Have you been driving professionally for more than 3 years, or driving without an at fault incident or less than 3 minor infractions for more than 3 years? *

Yes

Driving Record Background

(Applicants will be cleared through obtaining a Motor Vehicle Record)

Have you had a traffic moving violation in the last 3 years? *

Yes

Have you had any type of driving accidents in the last 3 years? *

Yes

Have your driving privileges ever been suspended, revoked or denied? *

Yes

Have you ever had a limousine or taxi driver certificate suspended or revoked by the authority due to a regulatory violation? *

Yes

Have you been charged with a DUI, reckless driving, leaving the scene of an accident, driving without a license or insurance or driving with a suspended license? *

Yes

Driver Criminal Background

(Applicants will be cleared through obtaining a Criminal Background Report

Have you ever been convicted of any of the following felonies within the last 10 years?

Driving under the influence of drugs and alcohol? *

Yes

Felony involving theft? *

Yes

Felony involving fraud? *

Yes

Felony for a violation of the act of April 14, 1972 (P.L.233, No.64), known as The Controlled Substance, Drug, Device and Cosmetic Act? *

Yes

Have you ever been convicted of any of the following within the last 10 years?

Felony in connection with a motor vehicle? *

Yes

Burglary or Robbery? *

Yes

A sexual offense under 42 Pa.C.S. Section 9799.14(c) or (d) (relating to sexual offenses and tier systems) or similar offense under the laws of another jurisdiction or under a former law of this Commonwealth? *

Yes

(Applicants will be cleared through obtaining a Sam, OIG and Sex Offender Report)

A crime of violence as defined in 18 Pa.C.S. Section 5702(relating to definitions) or a similar offense under the laws of another jurisdiction or under a former law of this Commonwealth? *

Yes

An act of Terror? *

Yes

Contractor Experience

Are you willing and able to abide by all of the guidelines set forth under the Transportation Network Company guidelines? *

Yes

Number of years’ experience as an Independent Contractor?

Number of years as an Independent Contractor operating in the transportation business?

Have you in the past or do you currently drive for other transportation companies as an Independent Contractor? *

Yes

If yes, what companies?

Do you or your business currently have any employees? *

Yes

If yes, please list the names of all person(s) associated with your business

As much as practical, will you complete all job offers that have been accepted by you or an acting agent on behalf of your company? *

Yes

Will you hire or contract anyone to assist with completing job offers if need be? *

Yes

If No, please list your reasons for not doing so

Is it your business practice to give sufficient notice to the contractor when your company is not able to perform a job? *

Yes

If yes, please state the number of hours of prior notification

How often does your business practice turn back job offers? *

Often

Occasionally

Hardly Ever

Never

Please list some of the reasons why you had to turn back a job offer in the past?

Are you and your business willing to perform services to a satisfactory level so as to not disrupt or damage the integrity and business relations between our company and its clients? *

Yes

Are you willing to consider you or your business a voluntary quit for poor performance and excessive job no shows? Tardiness, turn backs and complaints? *

Yes

Were you involved or found guilty of any offense that now precludes you and your business from participating in any federally funded programs? *

Yes

Have you or anyone working for your business received a complaint for discrimination? *

Yes

If Yes, please explain the nature and outcome of the complaint. You may submit an attachment if you need more space.

Please identify all equipment to be used to complete job offers.

If this is a driving profession, please list the year, make, model, vin and plate number of all vehicles to be used in connection with job offers.

Is all the above listed equipment owned or registered to you or your business? *

Yes

(If No, please list the person(s) to whom the equipment belongs). All Equipment will be cleared through proof of ownership or registration card(s).

Is all of the equipment up to date, calibrated, inspected and fully operable to use in a public and professional setting. *

Yes

Vehicle Equipment Documents

Equipment documents will be cleared by providing a copy to the Company for review and record keeping.

Current Vehicle Inspection? *

Yes

Current Vehicle Registration? *

Yes

Current Vehicle Insurance? *

Yes

Vehicle Equipment Functions

Equipment will be cleared upon inspection made by our company.

Any dents larger than 12 inches across? *

Yes

Any loose body panels or bumpers? *

Yes

Functional door handles interior and exterior? *

Yes

Any vandalism or graffiti on the exterior of vehicles? *

Yes

Clean interior? *

Yes

Working seatbelts? *

Yes

Door seals are intact? *

Yes

Tears in the upholstery that exceed 3 inches? *

Yes

Windows are operational? *

Yes

Interior lights operational? *

Yes

Headlights are operational? *

Yes

Left and right turn signals are operational? *

Yes

Interior door locks functional? *

Yes

Doors aligned? *

Yes

Horn operational? *

Yes

Tires have 4/32 inch of tread? *

Yes

Functioning air conditioner to cool the interior of a vehicle between 60 to 78 degrees? *

Yes

Functioning heating system? *

Yes

Brakes fully operational? *

Yes

Emergency Brake operational? *

Yes

Cracks in side view mirrors restricting view? *

Yes

Any cracks in the driver area of the windshield or that restrict the vision of the driver? *

Yes

Additional Information

Lastly, please describe in your own words why you are electing to drive as an Independent Contractor? *

References

Do not use relatives. Include at least one business and one professional person. Please provide name, telephone number and occupation.

Reference 1 *

Reference 2 *

Reference 3 *

Emergency Contact

List the name and phone number of an emergency contact we could use to relay information on your behalf.

Emergency Contact *

PLEASE CAREFULLY READ THE FOLLOWING BEFORE SIGNING *

I hereby affirm that the information provided on this application is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration and may be considered for dismissal if discovered later. I authorize my current employer, previous employer and organization named in this application to provide the company with any relevant information that may be required to arrive at an employment decision.

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.