Patient Transporter

General Information

Applicant Name(Required)

First Last

Email Address(Required)

Enter Email Confirm Email

Phone(Required)

Alternative/Cellphone

Current Address

Street Address Address Line 2 City State ZIP Code

Education

Highest level of Education Completed?(Required)

High School

Vocational Training (i.e. HHA, CAN)

Some College

Bachelor's Degree

Graduate/Professional Degree

Are you currently enrolled?(Required)

Yes, currently enrolled

No, completed with Degree/Certificate

Did not finish (Withdrawal)

Work Experience

Are you currently employed?(Required)

Yes

No

Work Experience

List your last 3 places of employment in chronological order with present or most recent employer listed first that relate to this position or patient care. If this is your first job please state "First Job" inside the answer box.

Do NOT answer “See Resume”

Current and/or most recent employment and title:

Reason for leaving?

Starting Salary (per hour) / AND / Ending Salary (per hour)?

May we contact your current employer?

Employment 2

2 | Employment and title:

2 | Reason for leaving?

2 | Years of employment?

2 | Starting Salary (per hour) / AND / Ending Salary (per hour)?

2 | May we contact your current employer?

Employment 3

3 | Employment and title:

3 | Reason for leaving?

3 | Years of employment?

3 | Starting Salary (per hour) / AND / Ending Salary (per hour)?

3 | May we contact your current employer?

Personal references

Personal References

Please list the names of personal references (no previous employers or relatives) who you know that we may contact:

Reference 1 Name(Required)

First Last

Reference 1 Occupation(Required)

Reference 1 Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 1 Phone(Required)

Number of Years Known | Reference 1(Required)

Reference 2

Reference 2 Name(Required)

First Last

Reference 2 Occupation(Required)

Reference 2 Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 2 Phone(Required)

Number of Years Known | Reference 2(Required)

Upload Resume

Allowed file formats: .doc | .docx | .pdf

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 512 MB, Max. files: 2.

Driving Information

Do you have a current valid drivers license?(Required)

Yes

No

License No.(Required)

Licensed State(Required)

Expiration Date(Required)

If you do not have a driver’s license for the state in which you currently reside, why not?(Required)

Has your license ever been suspended or revoked?(Required)

Yes

No

Do you have valid personal automobile insurance?(Required)

Yes

No

Please explain | license suspended or revoked?(Required)

Please explain | non-valid automobile insurance(Required)

Short Answers

Have you ever had a DUI?(Required)

Driving under the influence

Has your license ever been suspended, if so why?(Required)

How many years of experience to you have in transportation?(Required)

Have you ever had your license suspended or taken away?(Required)

Have you done worked in home health previously?(Required)

Do you have experience with Alzheimer’s and dementia persons?(Required)

Are you CPR certified?(Required)

What is your comfort level in dealing with patients who have dementia, non-combative?(Required)

Criminal Background

Date of Birth(Required)

Last 4 of SSN

Have you ever been convicted of a misdemeanor offense?(Required)

State Yes or No | If yes, please explain.

Have you ever been convicted of a felony offense?(Required)

State Yes or No | If yes, please explain.

Applicant Certification

Application Certification Agreement

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand employees of the location, pursuant to the Company’s policy and federal state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of the continual employment and I agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable state, and local law.

If employed by the Company, I understand and agree that the Company, to the extent permitted by state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

I Have Read and Acknowledge the Above Certification

PH Transportation

Benefits of working at Patient Hands Home Care, LLC

Job Description

Online Application

General Information

Education

Work Experience

Work Experience

List your last 3 places of employment in chronological order with present or most recent employer listed first that relate to this position or patient care. If this is your first job please state "First Job" inside the answer box.

Employment 2

Employment 3

Personal references

Personal References

Reference 2

Driving Information

Driving Information

Short Answers

Criminal Background

Equal Employment Opportunity

Applicant Certification

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