Date of Application

Middle Initial

Mailing Address

City

State

ZIP Code

Home Phone

Cell Phone

Work Phone

Date of Birth

Social Security Number (SSN)

Position Applying For Select Position NEMT Driver Wheelchair Van Driver Dispatcher

Employment Type Desired Select Option Full-Time Part-Time Per Diem

Language skills other than English

Date Available for Employment

Have you ever been employed here before?

Are you legally eligible for employment in the US? Yes No

How did you hear about us? Internet Search Newspaper Ad Current Employee Reference Other

Emergency Contact Name

Relationship

Home Phone

Cell Phone

Work Phone

Interview Conducted By

Interview Date

Name of Interested Caller

Address

Phone Number

Email Address

Interviewing For (Position)

Our Proposed Pay Rate ($ / Hour)

Has caller ever worked in transportation before?

If yes, where?

Is caller currently working?

Time Desired Part-Time Full-Time

When will caller be available to work?

Any convictions/felonies hindering hiring process?

Days Available MON TUES WEDS THURS FRI SAT SUN

Availability Hours Details

DAY HOURS

EVENING HOURS

ANYTIME

Preferred Shifts Day Shifts Evening Shifts Anytime / Open Availability

Reference Company Name

Reference Address

Reference Phone Number

Reference Contact Email

Applicant Name (For release form)

Social Security Number

Position Applied For

Applicant’s Authorization to Release Information:
I hereby give permission for my previous employer to release this referral information about my position with their company and comments regarding my work ethic and character while employed with their company.

Reference Company Name

Reference Address

Reference Phone Number

Reference Contact Email

Applicant Name (For release form)

Social Security Number

Position Applied For

Applicant’s Authorization to Release Information:
I hereby give permission for my previous employer to release this referral information about my position with their company and comments regarding my work ethic and character while employed with their company.

Orientation Instruction Page Sign Up for All Employees

Urgent Transit uses a unique method to orient its new employee so that we ensure that every employee receives all the information needed on their hiring date.

We ask that you have in front of you the complete hiring packet and your job description prior to starting the exercise.

As you go through the package, each document will be reviewed. You should have the documents reviewed in front of you and you should read through it as we proceeded. As we finish each document you will sign and date each document and put it to the side in the order that we go through.

Use care on the document marked driver application. We require you to provide 2 references for your file. Fill in the name of the company or persons and their address that you would like to send the reference request to. If you do not know the address during orientation, please find out as soon as you leave today and call us before the day is over. Play the form us right away if you suspect that something negative will come back on your criminal background check. Not all convictions will eliminate you from working transportation, but you must understand that we are responsible for assuring the safety of vulnerable persons (elderly and children). Speak to the administrator privately if you suspect a problem will be identified.

Many transportation employees work for more than one company at a time. It is essential that you let us know if you are working for another agency. Remember that any patient you service for us is our client. Should you ever decide to leave us for any reason, the patient you are servicing for us may never be encouraged to transfer to another company where you might be working. This is clearly a conflict of interest and will not be tolerated. Our legal department will be notified immediately should this occur.

Please make sure that the documents required to start working for this transportation company are accounted for, those documents include a copy of the driver’s license, Social Security card, RMV driving record, completed drug test, completed fingerprints, associated training, CORI, ESORI and a copy of applicant’s physical.

I have read and agree to the Orientation Sign Up terms and conditions.

Urgent Transit Company Standards & Policies

Listed are some pertinent references of employee policies from the agency employee handbook. For more detailed information please refer to the handbook. You may request to review any/all the personnel policies pertinent to your employment at our agency at any time.

I acknowledge receipt of and agree to abide by all the rules, guidelines, and standards outlined in the Urgent Transit Employee Handbook. I understand that compliance with company standards is a condition of my ongoing employment.

I acknowledge receipt of the Employee Handbook and agree to abide by the Company Standards.

Offer Date

Offered Position Title

Start Date

Employment Location

Salary Offer ($)

Salary Unit per hour per year per trip

Employment Offer Letter (Conditional Employment) terms:

We are pleased to offer you a conditional position as listed above with Urgent Transit. This offer is conditional, pending the results/return of a Criminal History Background Check and Reference Checks (2 Required). You may begin orientation but cannot have direct contact with members or company equipment until these are cleared.

Offer Date

Offered Position Title

Start Date

Employment Location

Salary Offer ($)

Salary Unit per hour per year per trip

Employment Offer Letter (Permanent Employment) terms:

We are pleased to offer you a permanent position as listed above with Urgent Transit. Your employment location, salary details, and start date are as specified. Benefits are not currently offered.

Employee Name

Employee Title

Agreement Day

Agreement Month

Agreement Year

Confidentiality Agreement Terms

This agreement is made between Employee and Urgent Transit Inc. (the Employer). The employee agrees to the terms of this agreement:

1. As a condition of employment, the Employer requires that all new employees agree to enter into this confidentiality agreement. The Employee acknowledges that employment with Employer is sufficient consideration for the Employee to enter into this Agreement.

2. The employee acknowledges that, in the course of the employment, The employee will, and may in the future, come into possession of certain confidential information belonging to the employer, including but not limited to trade secrets, data, materials, products, technology, computer programs, specifications, manuals, business plans, software, marketing plans, financial information, and other information disclosed or submitted. This confidential information may be embodied in handwritten notes by the employee, computer disks, tapes, paper, or any other media.

3. The employee hereby covenants and agrees that she or he will at no time, during or after the term of employment with the employer, use for his or her own benefit or the benefit of others, or disclose or divulge to others, any such confidential information.

4. Upon termination of employment, the employee will return, retaining no copies or notes, all documents relating to the employer’s business including, but not limited to, reports, lists, correspondence, information, computer files, and all other material obtained by the employee during employment. Nor will the employee attempt to contact or solicit any clients that the employee may have worked with during employment.

5. The employee recognizes that the employer may be irreparably damaged by breach of this agreement, and that the employer shall be entitled to seek an injunction to prevent such competition or disclosure, and other legal remedies, including attorney’s fees and costs.

6. The obligations of the Recipient herein shall be effective from the date Owner last discloses any confidential information to the Recipient pursuant to this Agreement.

7. If any part of this agreement is adjudged invalid, illegal or unenforceable, the remaining parts shall remain in full force and effect.

8. This instrument constitutes the entire agreement of the parties. No representations or promises have been made except those that are set out in this agreement.

9. This agreement shall take effect as a sealed instrument and shall be construed, governed and enforced in accordance with the laws of the State of MA.

10. The descriptive headings used herein are for convenience of reference only, and they are not intended to have any effect in determining the rights or obligations under this agreement.

I agree to the Confidentiality Agreement.

Employee Name

Conflict of Interest Policy Overview

No employee or member of the governing bodies, advisor, committee, or individual, committee or entity shall derive any profit or gain, directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the governing body. All board members and/or employees, at the discretion and specific group request of the Board, will be required to submit a disclosure statement annually.

If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Administrator and Governing body. In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency, and the board member shall not participate in discussions unless requested by the board nor vote on such transactions.

Field staff in any capacity understand that all clients are clients of the agency, not personal clients of the Field staff. Clients may never be serviced privately by the employee of the agency for the financial gain of the employees. Should any employee terminate their employment with Urgent Transit Inc., the field staff understand that the patient may not be encouraged or otherwise moved from our agency to another agency.

Individual Statement Regarding Conflict of Interest:
I have read and I am fully familiar with the company's policy statement regarding conflict of interest. I am not presently involved in any transactions, investments, or other matters in which I would profit or gain directly or indirectly because of my employment. Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the agency's business that might result in any profit or gain, directly or indirectly for myself.

I agree to the Conflict of Interest Individual Statement.

Employee Name

Employee HIPAA Compliance Agreement

I, as an employee of Urgent Transit LLC, have read and understand this policy on protecting Patient Health Information (PHI) and security. I understand that should any situation arise where I breach patient confidentiality, I will be disciplined up to and including termination.

I hereby agree to maintain patient confidentiality in the strictest manner possible, sharing or discussing patient information only with those designated care providers or supervisors who have a "need to know" and are actively involved in care or services provided to the patient.

I further acknowledge that I have been trained in the laws related to HIPAA compliance and that patients must sign written permission to allow their health information (PHI) to be disclosed.

I further agree that I will protect PHI while driving in my vehicles servicing patients and will not allow any PHI to be visible inside my vehicle; I will not bring any PHI related to another patient into the homes or facilities of the patients I am servicing.

I agree to the Employee HIPAA Policy and patient confidentiality terms.

Equal Employment Opportunity Policy & Affirmative Action Program

Urgent Transit Inc. complies with nondiscrimination regulations under Title VII, Civil Rights Act of 1964; Vietnam-Era Veterans Readjustment Assistance Act of 1974; Section 504 of the Rehabilitation Act of 1973; the Americans with Disabilities Act of 1990; the Age Discrimination in Employment Act of 1967; and other applicable MA labor codes. Our Agency will hire, train, and promote people in all job quality classifications without regard to race, color, religion, national origin, age, disability, or history of disability (except where physical or mental abilities are a bona fide occupational requirement), veteran status, or sex. Managers and supervisors of the company will base decisions on employment to further the principle of Equal Employment Opportunity.

Our company shall review its employment practices periodically to ensure equal consideration is given. We disapprove of sexual, racial, disability, national origin, age, veteran, religious, and all other forms of harassment of any employee. Sexual advances, jokes, slurs, and other harassing behavior are strictly prohibited. We have a zero-tolerance policy for all incidents of harassment, which is terms for immediate termination.

I acknowledge that I have read and understand the Equal Employment Opportunity Policy.

Driving Record Guidelines

For a driver to be approved, the following criteria must be met:
- Maximum of 1 moving violation in the last 3 years in combination with one at-fault accident.
- Maximum of 2 moving violations in the last 3 years with no at-fault accidents.
- Maximum of 2 at-fault accidents in the last 3 years with no moving violations.
- No speeding over 80 miles per hour.
- All drivers must be licensed for at least 3 years.

Any driver with any of the following in the last 3 years will not be accepted:
1. Suspension or revocation for other than failure to pay fines.
2. Driving under the influence of drugs or alcohol.
3. Careless Driving.
4. Negligent homicide arising out of the use of a motor vehicle.
5. Operating during a period of revocation or suspension.
6. Using a motor vehicle for the commission of a felony.
7. Aggravated assault with a motor vehicle.
8. Operating a motor vehicle without owner's authority.
9. Operating a motor vehicle while unlicensed.
10. Speed contests.
11. Any other criminal use of a motor vehicle.

As to drivers under 25 years old, the following guidelines apply:
1. No drivers under 21 years of age.
2. Drivers between 21 and 25 will be considered only with a clean MVR, no driving of 15-passenger vans, and valid license in effect for at least 3 years. Urgent Transit cannot hire more than 25% of drivers under the age of 25 or over the age of 74.

I certify that I meet all the Driver Guidelines and driving record rules.

Safe Driving Rules and Policies (15 Rules)

All staff driving on organization business are required to abide by specific driving rules. Individuals driving their own vehicles are no exception. The following rules must be followed:

1. Auto liability insurance must be always maintained on your personal vehicle.
2. Only preauthorized staff are permitted to operate vehicles for organizational purposes.
3. Drivers are responsible for timely maintenance in accordance with the vehicle guide.
4. All drivers are required to abide by federal, state, and local motor vehicle regulations.
5. All fines and other legal penalties arising from traffic citations are the responsibility of the driver.
6. A driver may not operate a vehicle at any time when his/her ability is impaired or influenced by alcohol, drugs, illness, fatigue or injury.
7. No driver may possess alcohol or illegal drugs in the vehicle being used for business purposes.
8. The driver and all occupants are required to wear safety belts at all times.
9. Only authorized passengers are permitted in the vehicle during business use.
10. No driver may possess weapons such as firearms, tasers, or the like in any company vehicle.
11. Drivers shall not pick up hitchhikers.
12. Drivers shall not use any radar detector, laser detector, or similar devices.
13. Drivers should not use cell phones during transport of clients or while driving.
14. Drivers are required to notify supervisors of any tickets or accidents they receive.
15. Drivers are required to notify their supervisor immediately if their license is suspended or revoked.

I agree to follow all 15 Safe Driving Rules and Policies.

I understand that if I'm employed, false statements on this application shall be considered sufficient cause for dismissal. This company is authorized to make any investigations of my prior educational and employment history. I understand that employment is "at will" which means that either I or this company can terminate employment at any time, with or without prior notice, and for any reason not prohibited by a statute.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or drug test, or to sign a conflict-of-interest agreement and abide by its terms. I understand and agree to the information shown above.

Have you ever been convicted of violating any law? (Omit minor traffic violations) Yes No

Driver's Name

Residential Street Address

City, State, Zip Code

Do you have a valid driver's license? Yes No

Driver's License Number

Expiration Date

State

If you have held a license in another state during the past 36 months, list State and Dates:

Have you received any automobile related fines or convictions in the last 5 years? Yes No

I certify that all answers provided to the questions on this form are true to the best of my knowledge. I understand that any misstatement of facts on this form may be grounds of termination of employment.

I authorize Urgent Transit LLC or its designated representative to obtain information regarding my driving record in any state at any time while I am employed by or seeking employment with this company, Urgent Transit LLC.

I understand that I am applying for a position that involves my operation of a motor vehicle, as a part of my responsibilities, that any employment offering is contingent upon my submission of a valid Massachusetts or other state driver’s license and upon receipt of the driving record accessible to both Urgent Transit LLC and its insurer. I also understand the receipt of the driving record that is unacceptable to Urgent Transit LLC and its insurer at any time may result in termination of employment.

I authorize Urgent Transit to obtain my Motor Vehicle Report (MVR).

Driver License (Color copy)

Social Security Card (Color copy)

Drug Test Results

RMV Driving Record

CORI Consent Form

Fingerprint Receipt / Schedule

ESORI Document

Medical Physical Exam Card

Wheelchair Training Certificate