NEMT driver employment application: a printable form with license and driving history sections

How to use this application

Print one copy for every person who applies, and keep three things off it: the background check authorization, any conviction question your state restricts, and medical questions. Everything else is on the form below. Replace each bracket with your own entry, starting with the minimum age, which should match the strictest payer you serve. The common rules are side by side in NEMT driver requirements.

The form is built on 49 CFR 391.21, the federal rule that lists what an application for a commercial motor vehicle driver must contain. If your drivers are covered, the form carries every required item once you add the two notes marked below: date of birth and Social Security number in Part 1, and the seven-year employer list in Part 4 for jobs that need a commercial driver’s license. If they are not, the same fields are still a complete record of license, driving, and work history. The driver file checklist shows where the finished application goes, and the wider hiring sequence is in how to hire NEMT drivers.

The application form

Part 1: About the applicant

Date of birth and Social Security number belong on this page only if 49 CFR 391.21(b)(2) applies to your drivers, because that paragraph lists both. For every other applicant, the age question above is enough until you make an offer.

Part 2: Licenses held in the past 3 years

Name each state that has licensed you or given you a permit, even one you have since left. Driving records are requested from each state, so a missing state is a missing record.

Has any license, permit, or privilege to drive ever been denied, revoked, or suspended? Yes / No. If yes, describe what happened, when, and where.

Part 3: Crashes and violations in the past 3 years

List every crash you were in, and every traffic violation you were convicted of or paid a forfeited bond for. Leave out parking tickets.

Write “none” if there is nothing to list. Vehicles and equipment you have driven professionally (van, bus, taxi, sedan, truck), and for how long:

Part 4: Employment in the past 3 years

Notice to applicants: the employers you list here may be contacted to confirm your dates, your safety record, and any drug or alcohol test results, and the information they send may be used in the hiring decision. If any of those jobs was regulated by the U.S. Department of Transportation, you may review what past employers send us, ask them to correct errors, and attach a statement of your own to any information you say is wrong.

For each job above, also answer two questions: Were you subject to the Federal Motor Carrier Safety Regulations in that job? Was it a safety-sensitive job in a transportation mode that requires drug and alcohol testing under 49 CFR part 40? Write Yes or No beside each employer. Explain any gap longer than [3 months] here:

[For jobs that need a commercial driver’s license, add this line.] List every employer in the 7 years before those 3 years for which you drove a commercial motor vehicle, with the employer’s name and address, your dates, and your reason for leaving:

Part 5: Training and certificates

Check each one you hold. Bring the card or certificate to your interview.

Part 6: The work and your availability

This job requires [driving up to __ hours a shift, pushing a rider in a wheelchair up a ramp, lifting up to __ pounds, and fastening floor tiedowns and belts]. Can you do these duties with or without a reasonable accommodation? Yes / No

In compliance with federal law, everyone hired must show who they are and that they may work in the United States, and complete Form I-9. [Company name] is an equal opportunity employer. If you need help completing this form or an accommodation for an interview, contact [name, phone, email].

Part 7: Certification and signature

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Questions that stay off a pre-offer form

The longer list of questions to leave out before an offer is in the interview questions guide. Five of them tend to turn up on application forms.

• Medical conditions and injuries. The EEOC bars disability-related questions before a conditional offer and says employers may not ask about job-related injuries or workers compensation history. You may state the physical demands and ask if the applicant can meet them, which is what Part 6 does. The same guidance lets you ask about education, work history, and required certificates and licenses.
• Date of birth and Social Security number. See the note under Part 1. The EEOC’s general rule is that pre-employment information should be limited to what is essential for deciding whether a person is qualified.
• Citizenship. Most employers should not ask whether an applicant is a citizen before an offer, the EEOC says, and Form I-9 and E-Verify cannot start until the employee accepts one. The one-line statement in Part 6 is modeled on the wording the EEOC suggests for applications.
• A photograph. The EEOC says not to ask for one. Take it for the ID badge after the offer is made and accepted.
• Conviction history. The next sections cover this one.

Why the background check authorization is a separate page

The disclosure that you may order a consumer report has to be a document by itself, and the FTC says it cannot sit inside the application. The statute allows the applicant’s written authorization on that same page, so one signed page does both jobs. Build it as a one-page form carrying the disclosure and the authorization, and hand it to every applicant you plan to screen. The FTC allows a short description of what consumer reports are, as long as it does not confuse or detract from the notice.

One narrow exception exists. Under 15 U.S.C. 1681b(b)(2)(B) and (C), an applicant for a position where the Secretary of Transportation sets qualifications and maximum hours, or one subject to safety regulation by a state transportation agency, may receive the notice and give consent orally or electronically, but only if the applicant’s contact so far has been by mail, telephone, computer, or similar means. An in-person interview before the report is ordered ends the exception, so the separate paper page is the safe default. The steps after the report comes back, including the pre-adverse action notice, are in the background check guide and the pre-adverse action notice entry.

When can an application ask about convictions?

Only when your state and city allow it, and several states and cities now push the question back until after an interview or an offer. Three examples show how much it varies:

• Washington. RCW 49.94.010 bars an employer from including any question about criminal record on an application, and from asking until it has decided the applicant is otherwise qualified and made an offer conditioned on the record. The attorney general says the 2025 amendments take effect July 1, 2026 for employers with 15 or more employees and January 1, 2027 for smaller ones. Employers that law expressly permits or requires to consider criminal records are exempt.
• Illinois. Under 820 ILCS 75/15, an employer with 15 or more employees may not inquire about or consider an applicant’s criminal record until the applicant has been selected for an interview, or after a conditional offer if there is no interview. Positions where federal or state law requires excluding applicants with certain convictions are exempt, and the exemption names federal or state law, not a clause in a broker contract. The statute also lets you tell applicants in writing which specific offenses will disqualify them.
• California and New York City. Each has its own fair chance law with its own timing and notice steps. The criminal record hiring guide covers them alongside the disqualifying offenses by program.

Where the question is restricted, replace the checkbox with a printed line such as “Our contracts disqualify applicants with [list of offenses]. A background check follows a conditional offer.” That tells the applicant the standard without asking anything.

From application to driver file

Each state listed in Part 2 is a separate request. For drivers covered by the federal safety rules, 49 CFR 391.23(a)(1) requires you to ask every state that licensed the driver in the past three years for a driving record within 30 days of the start of employment, so the list on the form becomes your order list. The employers in Part 4 are the calls described in verifying a driver’s employment history.

The finished application is the first document in the file. For a driver covered by the federal rules, 49 CFR 391.51(b)(1) puts the application in the driver qualification file, and paragraph (c) keeps the file until three years after the driver’s employment ends. For everyone else who applies, the EEOC rule at 29 CFR 1602.14 sets one year from the record or the hiring decision, counted from the later of the two. The employee record retention guide gives the rest of the schedule.

Once the driver is hired

Enter the license, passenger assistance, CPR, and defensive driving dates from Parts 2 and 5 in HealthRide’s fleet and credentials records. Reminders go out before each date comes due, and dispatch sees a flag when an expired credential is on a trip being assigned.