ModivCare Independent Driver Questionnaire
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
What is the BEST way to reach you?
Text
Call
Email
When is the BEST time to contact you?
Morning
Afternoon
Evening
Do you own your vehicle? This is a REQUIREMENT for this job.
*
Yes
No
Model of vehicle:
Year of vehicle:
Make of vehicle:
Do you have at least liability insurance? This is a REQUIREMENT for this job.
*
Yes
No
Have you previously or do you now work for a transportation provider contracted with ModivCare?
Yes
No
How did you hear about ModivCare?
Are you related to or friends with any ModivCare employee?
Yes
No
If so, who?
Have you ever worked as a volunteer driver?
Yes
No
If you have, when?
Have you ever been convicted of a felony?
Yes
No
Describe the charges:
When you need directions, what type of mapping device do you use?
What days/hours are you available to drive?
From
To
SUN
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
MON
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
TUE
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
WED
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
THUR
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
FRI
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
SAT
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
N/A
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
1am
2am
3am
4am
5am
6am
How many miles are you willing to travel one way?
0-60
60-80
80-100
Over 100
Willing to drive throughout the state of West Virginia
Additional comments:
Submit
Should be Empty: