Transportation Employment Form

Experience unparalleled care with Compassionate Care Transportation, your trusted partner in providing personalized home care and safe transportation for seniors and individuals with disabilities. Together, let’s create a world where every journey matters and every ride is filled with comfort and compassion.

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Desired Position

Application Date

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Enter the Desired Position *

Desired Salary: $ *

Personal Information

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Full Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Driver's License Number

Mobile Number

Alternative Phone

Email *

Date Of Birth *

Last 4 Of Social Security

Availibility: Days Or Nights Circle One)

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Will You Work With Pets In The Home? *

Will You Work With Smoking Client? *

Do You Have An Insured Vehicle? *

How Did You Hear About Us Please Be Specific

Will You Perform Pet Care? *

Are You Willing To Drive? *

DISCLAIMER AND SIGNATURE

I hereby authorize (agency) to request and receive from all prior employers, within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.

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Signature *

Date *

EMPLOYMENT HISTORY

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Job Title *

Phone Number *

Employed from *

Supervisor Name & Title *

To *

Reason for leaving *

Company Name & Address *

Add Another Employment Entry...

Education History

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High School

Graduated

Location

Course Of Study

Type Of Degree

Add Another Education Entry...

Compassionate Care Transportation

CERTIFICATIONS

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CERTIFICATION/LICENSE TYPE

Issued Date *

Number

Expiration Date *

Issued By

Add Another Certificate/License Entry...

MILITARY SERVICE

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Military Veterans?

Honorable Discharge?

REFERENCES

List Three Persons, Excluding Relatives Or Friends, As Professional References.

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Full Name *

Business Address & Phone *

Occupation/Title

Years Known

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Did You Receive Any Discipline In Your Last 12 Months Of Employment With Your Previous Employer?

Have You Ever Been Discharged Or Asked To Resign From Employment?

SKILL SET/EXPERIENCE

(Check those that apply)

Personal Information:

(Check those that apply)

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Have You Ever Applied To/worked For Compassionate Care Transportation. Before? If Yes, Please Explain (Include Date)

Have You Ever Been Convicted Of A Felony?

If Hired, Would You Be Able To Present Evidence Of Your U.S. Citizenship Or Proof Of Your Legal 1ight To Work In The United States?

Do You Have Any Friends, Relatives, Or Acquaintances Working For Compassionate Caregivers Home Care?

Are You Over The Age Of 18?

The Company Complies With The Ada And Considers Reasonable Accommodation Measures That May Be Necessary For Eligible Applicants/employees To Perform Essential Functions. It Is Possible That A Hire May Be Tested On Skill/agility And May Be Subject To A Medical Examination Conducted By A Medical Professional.

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Have you ever been included in any exclusion list (OIG) related to performing healthcare services?

Do You Consent To A Background Check?

(We Do Not Share Results Of The Background Check With Third Parties.)

Compassionate Care Tansportation

(Note: No applicant will be denied employment solely 011 the grounds of co11viclion of a criminal offense. The date of the offense, the nature of the offense, i11c/11di11g any significant details that affect the description of the evelll, and the surro1111di11g circ11111stances and the relevance of the o.fJe11se to the position(s) applied/or may, however, be considered.)

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Additional Information Do You Speak, Write Or Understand Any Foreign Languages?

Do You Have Any Other Experience, Training, Qualifications, Or Skills Which You Feel Should Be Brought To Our Attention, In The Case That They Make You Especially Suited For Working With Us?

In The Event Of An Emergency, Notify Or Contact The Following Person

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Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship

Phone

Declaration

Please Read And Initial Each Paragraph, Then Sign Below *

I Certify That I Have Not Purposely Withheld Any Information That Might Adversely Affect My Chances For Hiring. I Attest To The Fact That The Answers Given By Me Are True And Correct To The Best Of My Knowledge And Ability. I Understand That Any Omission (Including Any Misstatement) Of Material Fact On This Application Or On Any Document Used To Secure Employment Can Be Grounds For Rejection Of My Application Or, If I Am Employed By This Company, Grounds For My Immediate Expulsion From The Company.

I Certify That I Have Not Signed Any Non-compete Or Non-solicitation Agreement Or Any Other Kind Of Agreement With Any Other Employer That Might Restrict Me From Working For This Company. *

I Certify That I Have Not Signed Any Non-compete Or Non-solicitation Agreement Or Any Other Kind Of Agreement With Any Other Employer That Might Restrict Me From Working For This Company.

I Give the Company My Permission to Take My Photo for Company Use. *

I Give the Company My Permission to Take My Photo for Company Use.

I Understand That All Arrangements Relative To Assignments And Any Modification Of Terms Must Be Referred To And Approved By The Company, And That I Should Not Make Any Independent Agreements And/Or Arrangements With The Patients/Clients Without First Consulting The Company. *

I Understand That All Arrangements Relative To Assignments And Any Modification Of Terms Must Be Referred To And Approved By The Company, And That I Should Not Make Any Independent Agreements And/Or Arrangements With The Patients/Clients Without First Consulting The Company.

Signature

Date

An Equal Opportunity Employer

Company Is An Equal Opportunity Employer. This Application Will Not Be Used For Limiting Or Excluding Any Applicant For Employment On A Basis Prohibited By Local, State, Or Federal Law. Applicants Requiring Reasonable Accommodation In The Application And/Or Interview Process Should Notify A Representative Of The Organization.

This Application Will Be Kept On File For One Hundred Twenty (120) Days From The Date Completed. If Not Assigned After This Time, A New Application Must Be Completed For Consideration Of Employment.

Compassionate Care Transportation

Applicant's Consent to Drug Screen

Drug and Alcohol Test Policy
I understand it is the policy of Compassionate Caregivers Home Care LLC to conduct drug and/or alcohol tests of job applicants for the purpose of detecting drug and/or alcohol abuse. One of the requirements for consideration of employment with Compassionate Caregivers Home Care is the satisfactory passing of the Compassionate Caregivers Home Care LLC drug test. For the purpose of being further considered for employment, I hereby agree to submit to a drug test. I understand that favorable test results will not necessarily guarantee that I will be employed by Compassionate Caregivers LLC. I also understand that if I test positive for any drugs that have the potential to alter the body's mental and or physical state whether legal or illegal, I hereby agree to issue Compassionate Caregivers Home Care LLC, a copy of results of a 15-panel drug screen. Drug screen is to be performed under the direction and documentation of a medical review officer at a state-approved occupational health/medicine clinic. I understand that I will be responsible for the payment of this screening. If I am accepted for employment, I agree to take a drug test whenever requested by Compassionate Caregivers Home Care LLC. I understand that the taking of such tests is a condition of my continued employment. I also give consent to the testing agency to release to Compassionate Caregivers Home Care LLC, and other officially interested parties the results of my tests.

Consent

I, consent to this and verify that the sample I have provided is my uncontaminated sample. I understand that if this test fails, I will be responsible for completing additional testing at my own expense. This must be completed within 24 hours of the failed initial test and at an outside laboratory.

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Signature

Printed Name of Applicant *

Date

Signature of Witness

Drug Screen Record

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Date and Time of Testing

SSN: XXX-XX

Drug screen 15 panel.** Results

Test performed by:

Name of Applicant/ Employee

Date Of Birth

Lot # of testing kit

Title of person performing test:

CMPCGR: Drug Screen Consent Form

Compassionate Care Transportation

Pre-Employment Background Check Authorization

I,understand that as part of the employment process, Compassionate Care Transportation needs to complete a background check on me regarding: *

I,understand that as part of the employment process, Compassionate Care Transportation needs to complete a background check on me regarding:

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1. Criminal record;
2. Sex and Violent Offenders Record;
3. Employment Verification;
4. Education Verification;
5. License Verification;

6. Motor Vehicle Records;
7. Personal/Professional Reference Verification;
8. Medical Suitability;
9. Drugs/Alcohol;
10. Child Abuse Clearance (if indicated).

- I authorize all federal and state agencies, persons, and organizations that may have information relevant to this research to disclose such information to Compassionate Caregivers Home Care LLC or its authorized agent(s).
- I understand that this authorization is to be part of the written and signed employment application.
- I also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.
- I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant state law.
- I further authorize that a photocopy of this authorization may be considered as valid as the original.
- I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Compassionate Care Transportation Care LLC is contingent upon successful completion of a background check.

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Signature

Full Name *

Former Name(s) and Date(s) used

Date of Birth

Social Security Number

Current Driver’s License

Date

Telephone No.:

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

State

List any other cities, states, and dates of residency during the last 10 years (use the back of the sheet, if necessary)

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City

State

From: Month/Year

To: Month/Year

End Repeater

Add Another Residency Record ...

Likert Scale

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Item #1	Item #1 Strongly Disagree	Item #1 Disagree	Item #1 Neutral	Item #1 Agree	Item #1 Strongly Agree
Item #2	Item #2 Strongly Disagree	Item #2 Disagree	Item #2 Neutral	Item #2 Agree	Item #2 Strongly Agree
Item #3	Item #3 Strongly Disagree	Item #3 Disagree	Item #3 Neutral	Item #3 Agree	Item #3 Strongly Agree

Name

Transportation Employment Form

APPLY NOW

Desired Position

Personal Information

Availibility: Days Or Nights Circle One)

DISCLAIMER AND SIGNATURE

EMPLOYMENT HISTORY

Education History

Compassionate Care Transportation

CERTIFICATIONS

MILITARY SERVICE

REFERENCES

SKILL SET/EXPERIENCE

Personal Information:

Compassionate Care Tansportation

In The Event Of An Emergency, Notify Or Contact The Following Person

Declaration

An Equal Opportunity Employer

Compassionate Care Transportation

Drug Screen Record

Compassionate Care Transportation

List any other cities, states, and dates of residency during the last 10 years (use the back of the sheet, if necessary)

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