Independent Contractor Questionnaire: Driver

Independent Contractor Questionnaire: Driver
This questionnaire is to ensure you are the right fit for this position, and to make sure that you have all the requirements to be contracted within TransMedCare.

By signing below I agree and acknowledge the above statements.
For insurance purposes, are you 25-years or older?*

YesNo
Can you legally work in the United States?*

YesNo
Are you willing to authorize a background, employment verification, drug test (upon contract), and MVR check in accordance with local law and regulations?*

YesNo
Can you reliably commute to TransMedCare's location?*

YesNo
Are you available to commit 5-10 consecutive days per trip? This means you are not coming back to Orlando on a daily basis.*

YesNo
Are you comfortable traveling the 48 continental states and flying in an airplane?*

YesNo
Are you comfortable driving in snow and using snow chains?*

YesNo
Do you have experience driving cargo van or a heavier type of vehicle?*

YesNo
Are you allergic to pets?*

YesNo
Are you able to lift 100lbs assisted?*

YesNo
Are you able to read, write, and understand English?*

YesNo
Do you understand that as an independent contractor, you would not be eligible for unemployment benefits at the end of any contract with TMC?*

YesNo
Do you understand that as an independent contractor, you would be responsible for payment of any and all state and/or federal income taxes, Social Security, self-employment taxes, unemployment taxes, and payroll taxes and that you will receive a form 1099 for service provided to TMC by you?*

YesNo
Have you ever been contracted with TransMedCare (TMC) before?*

YesNo
Please indicate when:
Did someone refer you for this independent contractor service?

YesNo
Name of referral:

First NameLast Name
You will have to provide the following documents that are required to be contracted with TransMedCare. Not needed at this time, but will be needed after the screening process:
- Valid Driver's License (required)
- DOT Medical Certificate (required)
- PASS Certificate (required)
- Defensive Driving Certificate (required)
- LLC Registration (optional)
- Workers' Compensation Exempt (optional)
This certifies that this questionnaire was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Name

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty: