Driver Application You can complete the Driver Application form below. Please read our Driver Application Information sheet for more information on driver requirements and responsibilities. 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License Information:Do you have a City of Milwaukee issued (PPL) Public Passenger Drivers License?YesNoIf yes above what is the license #? Expiration Date MM slash DD slash YYYY WI Driver’s License Number Are you certified to handle wheelchairs?YesNoDo you have a valid First Aid/CPR certification?YesNoAccident Record for the Past 5 years:Nature of Accident Accident Date MM slash DD slash YYYY Fatalities Injuries Add second accident info? Yes No Nature of Accident Accident Date MM slash DD slash YYYY Fatalities Injuries Add third accident info? Yes No Nature of Accident Accident Date MM slash DD slash YYYY Fatalities Injuries Driving Experience:Have you driven a medical van in the past?YesNoIf yes for how long? If you drove a medical van in the past for what company? Employment History Questions:Have you ever been convicted of a felony? Yes No How did you hear about us?SelectWebsiteFlyerRadioVehicle decalJob Fair/ AgencyStreet/Yard SignEmployee ReferralOtherIf part time tell us when: (check all that apply) Week days-daytime hours. Week end-daytime hours. Week days-evening hours. Week end-evening hours. To Be Read And Signed By ApplicantThis 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 an employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.Do you authorize American MedTrans to run a personal and employment background check?* Yes, I approve No Enter Today's Date* Untitled NameThis field is for validation purposes and should be left unchanged.