Jax Patient Care is accepting applications for Patient Care Transportation.

To ensure proper consideration, please fill in the information below as completely and accurately as possible.

Office Address is 3563 Philips Highway STE: 506, Jacksonville, FL 32207

Position You Are Applying For? *

Driver Patient Care Technician (Minimum 3 Years Driving Experience)

Call Center Office

Personal Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email Address *

How Many Years of Driving Experience Do You have? (non-professional and professional) *

Date of birth * +

Gender? *

Ethnicity? *

Education Level, Location *

What Particular Experience and Qualifications Have You For Non Emergency Medical Transportation?

What Particular Experience and Qualifications Do You Have For Account Management and Administrative Office?

Indicate Skills Relating To Office Experience *

How Many Hours Weekly Can You Work?

Can You Work Nights?

Do You Have A Restrict?

Do You Need To Be Off At A Certain Time?

Are you legally authorized to work in the United States? *

Yes

No

Have you ever been convicted of a crime? *

No

Yes Yes

If Convicted *

Type of Convicted?

N/A N/A

Availability

Jax Patient Care operates 7 days, 24 hours, light on the weekends, and MUST be available Monday thru Saturday. Indicate any all days available. *

Shift preference: Start times vary by day and can be as early as 4:00 AM up until 4:00 PM. Schedules vary based on trip schedules. Some long trips occasionally. We are doing hospital discharges that could be throughout the day and night hours. Our mornings and afternoons tend to be the busiest with appointment pickups and drop-offs along with discharges and add-ons. *

Mornings-Early Afternoon

Late Morning -Evening

Any

Employment Desired *

Part Time

Full Time

Scheduling flexibility is a requirement. Start times we are hiring for can range from 8:30 AM to 4:00 PM, but end times can run from 4 PM to 12 AM. Rate your ability to be completely flexible for either of those shifts. *

Have some limitations listed below

Completely available

List Limitations List Limitations

Some patients can range in to the heavier side, how would you rate your self as moving via wheelchair a heavier (250lb. or more) patient safely up a low incline ramp or transferring from bed to stretcher? Also may involve tight quarters to properly attach restraints. *

Questionable

Some Limitation

No Problem

Other Other

Working a Saturday rotation is required. This will be working every other Saturday. Rate your availability. *

Every other

Unlimited

Not Available

Other Other

Occasional Sundays and Holidays are required *

Yes

No

Maybe Maybe

Do you have your own personal reliable transportation to get to office at designated time? *

Yes

No

Other Other

Employment History

Employer 1

Current or Previous Employer Name *

Address *

Phone

Start Date * +

End Date * +

Position *

Pay Rate *

Supervisor/Manager

Reason for Leaving *

May we contact? *

Yes

No

Phone Number

Employer 2

Previous Employer Name #2 *

Address *

Phone

Start Date * +

End Date * +

Position *

Pay Rate *

Supervisor/Manager

Reason for Leaving *

May we contact? *

Yes

No

Phone Number

Employer 3

Employer Name

Address

Phone

Start Date +

End Date +

Position

Pay Rate

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Employer 4

Employer Name

Address

Phone

Start Date +

End Date +

Position

Pay Rate

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

References

Reference 1

Reference Name *

Title *

Email Address

Phone *

Reference 2

Reference Name *

Title *

Email Address

Phone *

Reference 3

Name

Title

Email Address

Phone

Additional Skills

List any additional skills that you would like to mention.

Please submit a copy of your resume.

Disclosure and Background Check

In order to process your background Check, please provide the following Information. Include your extra legal name and any other name(s) you may have used In the last seven (7) years.

JAX PATIENT CARE APPLICATION RELEASE AND WAIVER OF RIGHTS

In exchange for the consideration of my job application by Jax Patient Care, I agree that

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either In the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Jax Patient Care, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written Instrument signed by directors and management of Jax Patient Care. Both the undersigned may end the employment relationship at any time, without specified notice or reason. If employed, Iunderstand that Jax Patient Care may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction In benefits.

I authorize Investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for ls cause for dismissal at any time without any previous notice. I hereby give Jax Patient Care permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release Jax Patient Care from any liability as a result of such contract.

I also understand that (1) Jax Patient Care has a drug and alcohol policy that provides for reemployment testing as well as testing after employment; (2) consent to and compliance with such policy Is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, In connection with the routine processing of your employment application, Jax Patient Care will request an investigative consumer report including Information as to my character, general reputation, personal characteristics, and mode of living. Upon written request from me, Jax Patient Care will provide me with additional Information concerning the nature and scope of any such report requested by It, as required by the fair credit reporting act.

I further understand that my employment with Jax Patient Care shall be probationary for a period of ninety (90} days, and further that at any time during the probationary period or thereafter, my employment relationship with Jax Patient Care Is terminable at will for any reason or no reason by either party.

Signature *

clear

JAX PATIENT CARE IS AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER. WE ADHERE TO A POLICY OF MAKING EMPLOYMENT DECISIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, SEXUAL ORIENTATION, NATIONAL ORIGIN, CITIZENSHIP, AGE OR DISABILITY. WE ASSURE YOU THAT YOUR OPPORTUNITY FOR EMPLOYMENT WITH JAX PATIENT CARE DEPENDS SOLELY ON YOUR QUALIFICATIONS.