AMT Driver Sign Up Form You can complete the Driver Sign Up form below. 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License Information:Do you have a valid driver's license*YesNoIf yes above what is the license #?* Expiration Date* MM slash DD slash YYYY State of issuance*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you certified to handle wheelchairs?YesNoDo you have a valid First Aid/CPR certification?YesNoHow did you hear about us?SelectWebsiteFlyerRadioVehicle decalJob Fair / AgencyStreet / Yard SignEmployee ReferralOtherDo you authorize American MedTrans to run a personal and employment background check?* Yes, I approve No To Be Read And Signed By Potential DriverThis certifies that I completed this form, 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. (Generally, inquires regarding medical history will be made only if and after approval of affiliation.) 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 form. In the event of affiliation, I understand that false or misleading information given in this form or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.Enter Full Name* First Last Enter Today's Date* NameThis field is for validation purposes and should be left unchanged.
