DIGNITY TRANSPORTATION INC.

We Turn Disability into Mobility

DRIVER APPLICATION

Date of Application

Personal Information

Last Name *

First Name *

Middle Name

Address *

Address 2

City *

Province *

Postal Code *

Resided less than 3 years? List previous addresses

Home Phone

Cell *

Email *

Emergency Contact

Relationship

Emergency Phone

Are You Presently employed? *

When are you available to start? *

Are there any physical limitations which may limit your ability to perform the job applied for? *

Referred By

Employment History (Last 5 Years)

Employer 1

Date From

Date To

Name of Company

Address

City

Province

Postal Code

Position Held

Salary/Wage

Contact Person

Position (Contact)

Phone Number

Type of Vehicle Driven

Reason for Leaving

Employer 2

Date From

Date To

Name of Company

Address

City

Province

Postal Code

Position Held

Salary/Wage

Contact Person

Position (Contact)

Phone Number

Type of Vehicle Driven

Reason for Leaving

Employer 3

Date From

Date To

Name of Company

Address

City

Province

Postal Code

Position Held

Salary/Wage

Contact Person

Position (Contact)

Phone Number

Type of Vehicle Driven

Reason for Leaving

Accidents & Infractions

Motor vehicle accidents (Past 5 years)

Date	Nature of Accident	At Fault?	Injuries?	Fatalities?

Criminal Offence Infractions

Date	Nature of Infraction	Province	Penalty

License & Eligibility

Attended driving school? *

License Number *

Expiry Date *

Class *

Issuing Province *

Denied license? *

Suspended/Revoked? *

Position Applying For

Drive DT Accessible? *

Drive Own Accessible? *

Drive DT Stretcher? *

Drive Own Stretcher? *

Own Vehicle? *

Documents

License (Front)

License (Back)

Abstract (PDF)

Resume (PDF)

First Aid (PDF)

Crime History (PDF)

I certify that all information provided is true and complete.

Signature (Typed) *

Date Signed