Become a Driver

Service Operator Location: *

Driver Type *

Name *

Email Address *

Driver License Number *

Drive License Issuing State *

Enter Years of Driving Experience

Social Security Number

EIN Number

Present Address

How long have you lived at your current address?

Previous Address

Years of formal education completed *

Currently Employed? *

List all employers for the past 5 years *

Number of years experience as a professional driver:

License now held, please select all that apply

Class A
Class B
Class C

Commercial Driver’s License Number(CDL) *

Are you willing to attend driver training courses? *

Are you willing to do a pre-employment background and drug screen? *

Do you consent to us doing a criminal background check? *

Do you consent to us performing a motor vehicle check? *

Are you willing to display our Company signage in your vehicle? *

Are you willing to allow the Company or any regulatory body agency overseeing this line of work inspect your equipment (to include personal or company vehicles)? *

Are you 21 years of Age or older? *

Have you been driving professionally for more than 2 years, or driving without an at fault incident or less than 3 minor infractions for more than 3 years? *

Do you have a current copy of your Motor Vehicle Driving Record? *

(Must be dated within 5 months of today's date.)

Have you had a traffic moving violation in the last 3 years? *

Have you had any type of driving accidents in the last 3 years? *

Have your driving privileges ever been suspended, revoked, or denied? *

Have you ever had a limousine or taxi driver certificate suspended or revoked by the authority due to a regulatory violation? *

Have you been charged with a DUI, reckless driving, leaving the scene of an accident, driving without a license or insurance, or driving with a suspended license? *

Have you ever been convicted of a felony within the last seven years? *

Yes
No

At any time during the applicant’s natural life, have you been convicted of the following? Please select all that apply. *

Number of years experience as an Independent Contractor?

Number of years as an Independent Contractor operating in the transportation business?

Have you in the past or do you currently drive for other transportation companies as an Independent Contractor?

Yes
No

If yes, what companies?

Do you or your business currently have any employees?

Yes
No

(If yes, please list the names of all person(s) associated with your business)

As much as practical, will you complete all job offers that have been accepted by you or an acting agent on behalf of your company?

Yes
No

Will you hire or contract anyone to assist with completing job offers if need be?

Yes
No

If no please list your reasons

Is it your business practice to give sufficient notice to the contractor when your company is not able to perform a job?

Yes
No

If yes, please state the number of hours of prior notification:

How often does your business practice turn back job offers?

Please list some of the reasons why you had to turn back a job offer in the past?

Are you and your business willing to perform services to a satisfactory level so as to not disrupt or damage the integrity and business relations between our company and its clients?

Yes
No

Have you or anyone working for your business received a complaint for discrimination?

Yes
No

If Yes, please explain the nature and outcome of the complaint

Vehicle Type

If other, please explain.

Select Year

Enter Make

Enter Model

Enter VIN

Enter Plate Number

Current Vehicle Registration?

Yes
No

Owned or registered to you or your business?

Yes
No

Is the vehicle inspection current?

Yes
No

Please select of the following insurance options you wish to use:

Name of Insurer:

Policy Number:

Policy Start Date: (MM/DD/YY)

Policy Expiry Date: (MM/DD/YY)

What are your auto coverage limits use drop down with following choices:

Does your insurance carrier have rideshare endorsements?

You will need to find a carrier that will endorse Ride4Health as a TNC provider.

Okay.

Is your insurance a commercial policy?

Yes
No

Does your policy meet the Primary automobile liability insurance that provides at least $500,000 for death, bodily injury and property damage?

Yes
No

Does your policy meet the First-party medical benefits as required by 75 Pa.C.S. § 1711 (relating to required benefits) on a per-incident basis for incidents involving a transportation network company driver's operation of a personal vehicle while engaged in a prearranged ride, including $25,000 for passengers and pedestrians and $5,000 for a driver?

Yes
No

Does your insurance carrier offer additional insured on their COIs?

Yes
No

You will need to find a carrier that will endorse Ride4Health.

Okay.

Is all of the equipment up-to-date, calibrated, inspected and fully operable to use in a public and professional setting?

Yes
No

Any dents larger than 12 inches across?

Yes
No

Any loose body panels or bumpers?

Yes
No

Functional door handles interior and exterior?

Yes
No

Any vandalism or graffiti on the exterior of vehicles?

Yes
No

Clean interior?

Yes
No

Working seatbelts?

Yes
No

Door seals are intact?

Yes
No

Tears in the upholstery that exceed 3 inches?

Yes
No

Windows are operational?

Yes
No

Interior lights operational?

Yes
No

Left and right turn signals are operational?

Yes
No

Interior door locks functional?

Yes
No

Doors aligned?

Yes
No

Horn operational?

Yes
No

Tires have 4/32 inch of tread?

Yes
No

Functioning air conditioner to cool the interior of a vehicle between 60 to 78 degrees?

Yes
No

Functioning heating system?

Yes
No

Brakes fully operational?

Yes
No

Cracks in side view mirrors restricting view?

Yes
No

Any cracks in the driver area of the windshield or that restrict the vision of the driver?

Yes
No

Name *

Contact Number *

Occupation *

Emergency Contact Name

Emergency Contact Phone Number

Lastly, Please describe in your own words why you are electing to drive as an Independent Contractor?

I hereby affirm that the information provided on this application is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration and may be considered for dismissal if discovered later. I authorize my current employer, previous employer and organization named in this application to provide the company with any relevant information that may be required to arrive at an employment decision. *

I AGREE

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Additional Locations

Philadelphia

Montgomery

Lancaster

Cherry Tree, PA

Easton, PA

Reading

Schuylkill, PA

Scranton, PA

Harrisburg

York, PA