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Employee Application

Applicant Information (* required)

First Name*:	Middle Initial:
Last Name*:
Address*:	City*:
State*:	Zip:
Phone 1*:	Phone 2:
Email*:
Position applying for (check all that apply):
Driver Dispatcher Customer Service Supervisor Other:
Location:	Evansville, IN Kansas City Leavenworth, KS Marion, IL Topeka, KS

Applicant History
Have you applied here before? Yes No If yes, when?:
How did you hear about ATS? Website Newspaper Employee Client Other:
Who referred you (if applicable)?:
Have you served in the U.S. Armed Forces? Yes No
Are you a U.S. citizen or authorized to work in the United States? Yes No

Criminal Background History
Have you ever been convicted of a crime? (This will not necessarily affect your application.) Yes No
If yes, please explain:


Emergency Contact
Name:
Phone:
Relationship:

Employment History (Start with most recent employer)
Company 1	Employed (MM/YY to MM/YY)
Address: City: State:
Phone: Position: Leaving Salary:
Reason for Leaving: Contact Person:
Was position safety sensitive under D.O.T.? Yes No
While employed here, did you undergo a D.O.T. Drug and/or Alcohol Test? Yes No
While employed here, were you subject to Federal Motor Carrier Safety Regulations? Yes No

Company 2	Employed (MM/YY to MM/YY)
Address: City: State:
Phone: Position: Leaving Salary:
Reason for Leaving: Contact Person:
Was position safety sensitive under D.O.T.? Yes No
While employed here, did you undergo a D.O.T. Drug and/or Alcohol Test? Yes No
While employed here, were you subject to Federal Motor Carrier Safety Regulations? Yes No

Company 3	Employed (MM/YY to MM/YY)
Address: City: State:
Phone: Position: Leaving Salary:
Reason for Leaving: Contact Person:
Was position safety sensitive under D.O.T.? Yes No
While employed here, did you undergo a D.O.T. Drug and/or Alcohol Test? Yes No
While employed here, were you subject to Federal Motor Carrier Safety Regulations? Yes No

References
Name:
Occupation:
Years Known:
Phone:
Relationship: Supervisor Co-worker Friend Other

Name:
Occupation:
Years Known:
Phone:
Relationship: Supervisor Co-worker Friend Other

Education
High School:		Completed
College:	Course of Study:	Completed
Trade/Other:	Course of Study:	Completed

Driver’s License History (list all types ever held)
State: License Number: Type/Classification: Expiration Date:
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
Has any of your license(s), permits or privileges ever been suspended or revoked? Yes No
If the answer to either of the above is yes, please provide an explanation:


Accident Review for past 5 years
Date: Nature of Accident: Results/Outcome:
Last Accident:
Next Previous:
Next Previous:
If none check No

Traffic Convictions & Forfeitures for the past 5 years
City/State: Date: Charge(s): Results/Outcome: If none check No

Applicant Questionnaire
Can you meet the minimum requirements of the position? Yes No
Are you interested in Full Time or Part Time? Full time Part Time
What is your salary requirement? $ per hour
What date are you available to start?
How many hours per week do you want to work?:
	Flexible 0-10 10-20 20-30 30-40 40+
How many days per week do you want to work?:
	Flexible 1 2 3 4 5 6 7
What days are you available to work?:
	Flexible Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What time are you available to start each day?:
	Flexible Before 6am 6am After 8am After 12pm
How late are you available to work each day?:
	Flexible 3pm-5pm 5pm-7pm After 7pm After 8pm
Are you able to work up to 12-hour shifts? Yes No
On-call may be required for this position. Are you able to participate? Yes No
Are you available to work Saturdays? Yes No
Are you available to work on Holidays? Yes No
Are you able to drive long distances? Yes No
What types of transports are you available for? All Ambulatory Wheelchair
Do you have previous professional driving experience? Yes No
If yes, please explain:
Do you have experience working with the elderly and disabled? Yes No
If yes, please explain:
Do you have experience working with individuals in wheelchairs? Yes No
If yes, please explain:
How familiar are you driving in the area? Very Familiar Somewhat Familiar Not Very Familiar
Can you read a map? Yes No
Can you follow directions? Yes No
Do you have previous dispatching experience? Yes No
Do you have computer experience? Yes No

In addition to your work history, are there any other skills, qualifications, or experience that we should consider?



Assisted Transportation is an Equal Opportunity Employer. Qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, age marital status or non-job related disability.