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Personal Details
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1
of 5
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Name
*
Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Email
*
Phone
*
Next
Layout
Company Name:
*
Position Held:
Layout
Dates of Employment:
From:
*
To:
*
Reasons for leaving(if applicable):
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Company Name:
*
Position Held:
Dates of Employment:
Dates of employment:
From:
*
To:
*
Reasons for leaving(if applicable):
Back
Proceed
Please list two professional references (no family members):
First Referee
First Referee
Name:
*
Relationship
*
Layout
Company:
*
Phone
*
Email
*
Second Referee
Second Referee
Name
*
Relationship
*
Layout
Company:
Phone
*
Email
*
Next
Do you have experience working in medical transportation, customer service, or a related field?
*
YES
NO
Are you physically able to assist patients weighing up to 350 lbs. with the use of equipment such as wheelchairs or stepping stools?
*
YES
NO
Why do you want to work for Tavros Non-Emergency Medical Transportation?
*
GDPR Agreement
*
By signing below, I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any misrepresentation or omission may result in disqualification from employment or termination if hired.
Previous
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Step
1
of 3
Layout
Name
*
First
Last
Phone
*
Email
*
Email
Confirm Email
Date of Birth
*
Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
Layout
Appointment Date
*
Pick Up Time
*
6:00AM
7:00AM
8:00AM
9:00AM
10:00AM
11:00AM
12:00PM
1:00PM
2:00PM
3:00PM
4:00PM
5:00PM
6:00PM
Pick up Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Appointment Time
*
6:00AM
7:00AM
8:00AM
9:00AM
10:00AM
11:00AM
12:00PM
1:00PM
2:00PM
3:00PM
4:00PM
5:00PM
6:00PM
Appointment Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Trip Type
*
One way
Round Trip
Do you wish for us to wait?
*
Yes
No
Drop off Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Service Type
*
Doctor appointment
Shopping
Dialysis
Elderly errands
Adult day out
Number of Persons
*
1
2
3
4
5
6
Vehicle Type
*
Sedan
Sedan
SUV
Van
Additional Information
Next
Layout
Heart Condition (Do you use Pacemaker?)
*
Yes
No
Are you on supplemental oxygen?
*
Yes
No
Are you on Dialysis?
*
Yes
No
Have you taken any sedative in the last few hours?
*
Yes
No
Do you have any valuables on you?
*
Yes
No
Do you have a primary doctor?
Yes
No
Layout
Doctor Name
*
First
Last
Primary Doctor Contacts
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Doctor Phone
*
Submit
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Layout
Name
*
Email
*
Phone
Date of incident
*
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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