COMPANION DRIVER APPLICATION FORM

COMPANION DRIVER APPLICATION

Please Read Carefully Before Signing the Authorization
PERSONAL DETAILS
Date*

MonthDayYear
Date
Name*

TitleLast NameFirst NameOther Name
Date of Birth*

MonthDayYear
Date
PLEASE ANSWER THE QUESTIONS BELOW
As an independent contractor for this position we are looking for applicants that are coachable, go-getters, entrepreneurial minded, self starter and team player. You must also be reliable, consistent, patient, caring and compassionate. Please describe how you exhibit each of these qualities.
Do you have a 4-door vehicle with adequate space for medical equipment (i.e., wheelchair, walker etc.)?
What is most attractive to you about this self employment opportunity?
Are you available to work with clients Mon through Fri during the hours of 6 am to 5pm? Some weekends?
Are you available to work half a day or the entire day?
Are you available to travel and service clients living in Williamsburg,Yorktown, Newport News, Hampton, Norfolk, Virginia Beach, Chesapeake, Suffolk, Portsmouth etc.?
Are you prepared to make the financial investment required to get started? This includes the purchase and printing of marketing materials,bond insurance, fuel for your vehicle, vehicle repairs & maintenance (if necessary) etc.
CONTACT DETAILS
Home Telephone*
Please enter a valid phone number.
Mobile*
Please enter a valid phone number.
Email*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 1 *
Name
Emergency Contact 1 Phone Number*
Please enter a valid phone number.
Emergency Contact 2
Name
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Please upload the following documents below:
Driver's License
Vehicle Registration
Vehicle Inspection Sticker/Report
Vehicle Insurance Card
Second Form of ID (ex. birth certificate, passport, voter ID, military ID)
Driver's License

Cancelof
Vehicle Registration

Cancelof
Vehicle Inspection

Cancelof
Vehicle Insurance Card

Cancelof
Second Form of ID (ex. birth certificate, passport, voter ID, military ID etc.)

Cancelof
LICENSE AND WORK VEHICLE DETAILS
Do you have a valid driving license?*

YesNo
If Yes, provide license #*
State Issued:*

MonthDayYear
Date
Exp. Date:*

MonthDayYear
Date
You are required to upload a picture of your driver's license here:

Cancelof
Do you have a car to use for work?*

YesNo
Make & Model of Vehicle:*
Year of Vehicle:*
Auto In Co:*
Policy #*
Exp. Date:*

MonthDayYear
Date
Please be informed that the Contractors’ Auto Insurance is the first in line for liability, and is the only policy that will fix the contractors car. Contractors are advised to inform their insurance company of the extent of their vehicle use on the job.
Have you submitted an application here before?*

YesNo
SECURITY
How long have you lived at your current Address? Months* Years*
If less than 5 years, provide prior address(s) with the time duration you live there:
Prior Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you had any moving traffic violations? Applicants with more than two moving violations within the past three years, more than two at-fault accidents within the past three years or any DUI/DWI or reckless driving conviction in the past seven years will not be approved.*

YesNo
Kindly describe:
Do you authorize Senior Runs to do a criminal and motor vehicle background check on you?*

YesNo
Have been convicted of felony or a misdemeanor or served time?

YesNo
Kindly describe incident (indicate city, state and charge):
REFERENCES
Kindly provide 3 references (at least 1 professional reference is REQUIRED), excluding relatives. We advise that you notify your references in advance that we will contact them. (Please note that your application will not be considered if you do not provide 3 references)

	Full Name	Phone Number	Email Address	Relationship	Years Known	Best Call Time
1.
2.
3.

Number
Calculation
APPLICATION PROCESSING FEE

Application Fee (non-refundable)

USD$50 Application Processing Fee

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Interview Questions Below

Please video record your answers. Each video should be 2 - 3 minutes in length. Use of web cam and headset maybe required. You may also upload a pre-recorded video.
State your full name, city and state you currently reside.
Please record your answer to the following questions - state your full name, the city and state you currently reside.
Please video record or upload your recorded video above.
We are currently hiring for two positions that of "Lead Driver" and "Floater".

What position are you interested? (i.e. lead or floater)

When you are available to start?

To be eligible for the lead driver position applicants must be available to work during our peak hours of Mon - Fri 5am - 4pm and willing to drive to all the major metro hubs (ex Richmond, Charlottesville Virginia Beach, Norfolk, DC etc.)

Floaters work on a more casual "part time" basis and may only be available a few days out of the week.
As an independent contractor for this position we are looking for applicants that are coachable, go-getters, entrepreneurial minded, self starter and team player. You must also be reliable, consistent, patient, caring and compassionate.

Please describe how you exhibit each of these qualities.
This position requires you to use your personal vehicle. What type of 4 door vehicle do you have (ex. sedan, suv, year, make, model)? You will be required to submit pictures of both the exterior/interior of your vehicle.
This position requires you to use your personal vehicle. What type of 4 door vehicle do you have (ex. sedan, suv, year, make, model)? You will be required to submit pictures of both the exterior/interior of your vehicle.
What is most attractive to you about this employment opportunity?
What is most attractive to you about this employment opportunity?
What makes you a good fit for this position?
What makes you a good fit for this position?
What does the word "Companion" mean to you?
What does the word "Companion" mean to you?
In this position your first priority is to serve as a companion. A companion is someone who assist, cares for, escorts and advocates for an individual. Describe any relevant experience you have in serving and caring senior citizens or individuals with mild or severe cognitive/physical challenges.
n this position your first priority is to serve as a companion. A companion is some one who assist, cares for, escorts and advocates for an individual. Describe any relevant experience you have in serving and caring senior citizens or individuals with mild or severe cognitive/physical challenges.
Providing a 5 Star customer experience is key to be successful in this position. Describe a time when you provided top notch customer service.
Providing a 5 Star customer experience is key to be successful in this position. Describe a time when you provided top notch customer service.
What relevant certifications, licenses, or training do you have? (ex. first aide, CPR, CNA, LPN, RN, PCA etc)
What relevant certifications, licenses, or training do you have? (ex. first aide, CPR, CNA, LPN, RN, PCA etc)
What is the best time and way to contact you? (i.e. phone, email, text message etc.)
What is the best time and way to contact you? (i.e. phone, email, text message etc.)
We are currently hiring for two positions that of "Lead Driver" and "Floater". To be eligible for the lead driver position applicants must be available to work during our peak hours of Mon - Fri 5am - 4pm and willing to drive to all the major metro hubs (ex Richmond, Charlottesville Virginia Beach, Norfolk, DC etc.) Floaters work on a more casual "part time" basis and may only be available a few days out of the week. What position are you interested? (i.e. lead or floater) and When you are available to start?
As an independent contractor for this position we are looking for applicants that are coachable, go-getters, entrepreneurial minded, self starter and team player. You must also be reliable, consistent, patient, caring and compassionate. Please describe how you exhibit each of these qualities.
DECLARATION
1. I declare that all the information I have given is true and that any false or misleading information may result in rejection of my application or discharge at any time during my employment.

2. I authorize Senior Runs and her agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records.

3. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background to Senior Runs and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

4. I release Senior Runs from any liability which might result from making such investigations.

5. I understand that the use of illegal drugs is prohibited during employment.

6. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of criminal background check.

7. I understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Senior Runs and me is terminable at-will, hence; both the company and I remain free to choose to end out work relationship at any time for any or no reason.

8. I understand that no amount of work can be guaranteed.

9. All changes in this employment relationship must be done in writing.

10. My signature below acknowledges that I have read, understood and agree to
the above disclosure.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

COMPANION DRIVER APPLICATION

PERSONAL DETAILS

PLEASE ANSWER THE QUESTIONS BELOW

CONTACT DETAILS

LICENSE AND WORK VEHICLE DETAILS

SECURITY

REFERENCES

APPLICATION PROCESSING FEE

Interview Questions Below

DECLARATION