# NEMT Driver Application Form: Free Printable With Background Check Consent

Canonical URL: https://nemtguide.com/templates/nemt-driver-application/ · Updated 2026-09-28

A NEMT driver application form collects an applicant's contact details, license, driving experience, work history, and availability, so you can check them against your broker's driver rules. The background check notice goes on its own page, as federal law requires. On this form, questions about convictions, medical conditions, and drug tests wait until after a conditional job offer.

- Keep the background check notice on its own page. Federal law bars putting it inside the job application.
- Ask whether applicants meet your broker's minimum age and license rules, not for their birth date or health history.
- Save conviction questions for after a conditional offer, as California requires of employers with five or more workers.
- Before you turn someone down over a report, give them a copy of it and the summary of rights, then wait before deciding.
- Keep every application for at least 1 year (4 in California), and shred background reports when you dispose of them.

A good driver application does two jobs. It tells you fast whether someone meets your broker's driver rules, and it gives you the signed permission pages you need before you pay for a background check. This form keeps those two jobs apart, because federal law and several state laws require it.

## How to use this template

1. **Fill in the company boxes before you print.** Copy your minimum age, license rules, and disqualifying offenses from each broker agreement you hold. MTM Health's standard agreement, in the January 1, 2023 version Pennsylvania posts, requires drivers and attendants to be at least 21. Its Virginia handbook (May 2026) adds two years of driving experience.
2. **List the physical tasks of the job in Part 1, section E.** Write the real weights and hours, such as lifting a folded wheelchair into the van.
3. **Give Part 1 to every applicant.** Use the same form and the same questions for everyone applying for the same job.
4. **Run the free exclusion searches.** Search the name from Part 1 on the [OIG exclusion list](https://nemtguide.com/glossary/oig-exclusion-list/) and SAM.gov, and record the dates in Part 7.
5. **Interview and road test.** Score each candidate the same way with the driver ride-along checklist.
6. **Make a conditional offer in writing.** Then hand over Parts 2 to 6. Print Part 2 on its own sheet and add nothing to it. California and Minnesota applicants also get a state notice on a separate sheet, and in Minnesota that notice goes out with Part 1 (see the state rules below).
7. **Order the checks only after Parts 2 to 4 come back signed.** Match your broker's definition of a background check. The steps are in NEMT driver background checks.
8. **File the pages in the right place.** Parts 1, 2, 4, 5, 6, and 7 start the [driver qualification file](https://nemtguide.com/templates/nemt-driver-file-checklist/). Keep Part 3 and any alcohol test result in a separate locked folder.

The full hiring order, with interview questions, is in [how to hire NEMT drivers](https://nemtguide.com/guides/hire-nemt-drivers/). After the hire, move to the [driver onboarding checklist](https://nemtguide.com/templates/nemt-driver-onboarding-checklist/).

## The template

### Part 1: Application for employment (every applicant)

Do not write your Social Security number, date of birth, or any health information on this part.

**Company boxes (the company fills these in before printing)**

| Field | Entry |
|---|---|
| Company name, address, and phone | |
| Job applied for (driver, attendant, or both) | |
| Minimum age for this job, from our broker agreements | |
| Minimum years of licensed driving for this job | |
| Attendance requirement (shifts, start times, weekends) | |
| Date this application was received | |

**A. About you**

| Question | Answer |
|---|---|
| Full name | |
| Mailing address | |
| Phone number | |
| Email address | |
| Best time to reach you | |
| How did you hear about this job? | |

**B. The job**

| Question | Answer |
|---|---|
| Which shifts can you work (early morning, day, evening, weekend)? | |
| Full time, part time, or either? | |
| Earliest date you can start | |
| Can you meet the attendance requirement written above? (yes or no) | |
| Are you at least the minimum age written above? (yes or no) | |
| If hired, can you provide proof that you may work in the United States? (yes or no) | |

**C. Your license**

| Question | Answer |
|---|---|
| Do you have a valid driver's license? (yes or no) | |
| State, license class, and expiration date | |
| Endorsements or permits you hold (passenger, chauffeur, for-hire, CDL) | |
| How many years have you held a driver's license, in any state? | |
| Every state that issued you a license in the last 3 years | |

**D. Experience with riders and vehicles**

| Question | Answer |
|---|---|
| Vehicles you have driven for work (sedan, minivan, wheelchair van with ramp or lift, stretcher van, bus) | |
| Experience helping people who use wheelchairs, walkers, or canes, or who need a hand | |
| Certificates you hold, with expiration dates (CPR, first aid, passenger assistance, defensive driving, wheelchair securement) | |
| Can you read, write, and speak English well enough to follow trip instructions and complete trip logs? (yes or no) | |
| Other languages you speak | |

**E. Physical tasks of this job**

| Task (the company fills in details) | Details |
|---|---|
| Help riders in and out of the vehicle | |
| Push a wheelchair up and down ramps and curbs | |
| Fold and lift a wheelchair or walker into the vehicle (weight) | |
| Operate a wheelchair ramp or lift | |
| Secure a wheelchair and rider with tie-downs and belts | |
| Drive for up to this many hours in a shift | |

| Question | Answer |
|---|---|
| Can you do the tasks above, with or without a reasonable accommodation? (yes or no) | |

**F. Work history, starting with the most recent job**

| Employer | City and state | Job title | From (month and year) | To (month and year) | Why you left | May we contact them? |
|---|---|---|---|---|---|---|
| | | | | | | |
| | | | | | | |
| | | | | | | |

**G. References (not family)**

| Name | How you know them | Phone |
|---|---|---|
| | | |
| | | |

**H. Your signature**

I certify that the answers on this application are true and complete. I understand that a false or missing answer may end my application, or my job if I am hired.

| Signature | Printed name | Date |
|---|---|---|
| | | |

### Part 2: Background check notice and permission (its own page, after a conditional offer)

**Notice.** [Company name] may obtain one or more consumer reports about you for employment purposes. A consumer report is a background report prepared by a screening company. It may include your criminal record, your driving record, a sex offender registry search, and verification of your license and past jobs. If you are hired, [Company name] may obtain new consumer reports about you at any time while you work here, such as a yearly driving record and background check.

**Permission.** I have read this notice. I authorize [Company name] to obtain consumer reports about me for employment purposes now and, if I am hired, at any time during my employment.

| Signature | Printed name | Date |
|---|---|---|
| | | |

### Part 3: Information for the background check (after a conditional offer)

This part goes only to the screening company. Keep it locked, apart from the driver file.

| Field | Entry |
|---|---|
| Full legal name | |
| Other names you have used (for record searches) | |
| Date of birth | |
| Social Security number | |
| Driver's license number and state | |
| Current address, and the date you moved in | |

| Previous addresses in the last 7 years | From (month and year) | To (month and year) |
|---|---|---|
| | | |
| | | |
| | | |

### Part 4: Driving record release (after a conditional offer)

I give [Company name] my written consent to obtain my motor vehicle record from every state that licensed me, now and at least once a year while I work here. The record will be used to decide whether I qualify to drive and to report my driving history to the Medicaid programs and brokers [Company name] works with.

| State that licensed me | License number | Years licensed there |
|---|---|---|
| | | |
| | | |

| Signature | Printed name | Date |
|---|---|---|
| | | |

### Part 5: Driving history and drug law statement (after a conditional offer)

Do not list arrests that did not lead to a conviction, sealed or expunged records, or cases closed through a diversion program.

**Our broker's disqualifying offenses and record limits (the company fills these in from each broker agreement)**

| Broker | Offenses and limits |
|---|---|
| | |
| | |

| Question | Answer |
|---|---|
| Moving violation convictions in the last 3 years (date, state, violation) | |
| Accidents while you were driving in the last 3 years (date, at fault or not, injuries or damage) | |
| Has your license been suspended or revoked in the last 5 years? If yes, when and why | |
| Have you been convicted of violating a state or federal drug law? If yes, the date, state, and offense | |
| Do you have a conviction or a pending charge for any offense in the broker list above? If yes, explain | |

If I am hired, I will tell [Company name] within ______ days of any ticket, accident, license suspension, arrest, or criminal charge.

| Signature | Printed name | Date |
|---|---|---|
| | | |

### Part 6: Drug and alcohol testing consent (after a conditional offer)

I have received [Company name]'s written drug and alcohol testing policy. I understand that I will be tested before I start work and, if hired, after any accident, when there is reasonable suspicion, and at random, as the policy explains. I consent to a pre-employment drug and alcohol test and to the release of my results to [Company name] and to any broker or state program whose contract requires them.

| Collection site | Date and time of test | Signature | Date |
|---|---|---|---|
| | | | |

### Part 7: Office use only

| Step | Date | Result or notes | Initials |
|---|---|---|---|
| Part 1 received | | | |
| OIG exclusion list search (copy saved) | | | |
| SAM.gov exclusion search (copy saved) | | | |
| State Medicaid exclusion list search, where one exists | | | |
| Interview and road test | | | |
| Conditional offer made in writing | | | |
| Parts 2 to 6 signed | | | |
| State notice given and copy box answered (California and Minnesota) | | | |
| Driving record received and compared with broker limits | | | |
| Background check received | | | |
| Drug and alcohol test result received | | | |
| Pre-adverse action notice sent, with the report and summary of rights | | | |
| Final decision (hired or not hired) | | | |
| Adverse action notice sent, if not hired | | | |
| Date the records may be destroyed | | | |

## Why the background check notice is its own page

The Fair Credit Reporting Act covers any background report you buy from a screening company, whatever your size. Before you order one, you must give a clear and conspicuous written notice, "in a document that consists solely of the disclosure," that a consumer report may be obtained for employment purposes. The applicant must then authorize the report in writing, and that permission may go on the same page ([15 U.S.C. 1681b(b)(2)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section1681b&num=0&edition=prelim)).

The FTC's guidance for employers (October 2016) adds three points:

- **Never inside the application.** The notice cannot be part of an employment application.
- **Little else on the page.** A brief description of what consumer reports are is allowed, but only if it does not confuse or detract from the notice. That is why Part 2 carries no release of liability, no questions, no job terms, and no state notices.
- **Say so if checks continue.** If the permission covers new reports during the whole job, such as a yearly driving record, it must say so clearly and conspicuously.

You also certify to the screening company that you gave the notice, got permission, and will not use the report to discriminate ([15 U.S.C. 1681b(b)(1)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section1681b&num=0&edition=prelim)).

Two variations to know:

- **Reference interviews.** A report built on interviews about a person's character, reputation, or way of life is an investigative consumer report. You must mail or deliver a written notice no later than 3 days after you request it, and describe the nature and scope of the investigation within 5 days of a written request ([15 U.S.C. 1681d](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section1681d&num=0&edition=prelim)).
- **Hiring entirely by phone or online.** A narrow exception lets you give notice and get consent orally or electronically. It covers only jobs whose qualifications and hours the U.S. Department of Transportation can set, or jobs under a state transportation agency's safety rules, and only when every contact so far has been by mail, phone, or computer. An in-person interview or road test ends it.

Background reports have limits too. Arrest records, civil judgments, and other negative items older than 7 years (10 for bankruptcies) generally cannot be reported for a job paying under $75,000 a year. Convictions can be reported however old they are ([15 U.S.C. 1681c](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section1681c&num=0&edition=prelim)). Part 3 asks for 7 years of addresses to match.

## Questions the application leaves out, and when to ask them

| Left off Part 1 | Why | What to do instead |
|---|---|---|
| Health, disabilities, medications, and injury or workers' compensation history | The ADA bars disability questions before an offer (EEOC guidance, October 10, 1995) | Ask whether the applicant can do the listed tasks with or without a reasonable accommodation, as one yes or no question |
| Date of birth and age | The EEOC says age is irrelevant to qualification, and age questions can be used as evidence of discrimination | Ask whether the applicant meets your minimum age. Collect the birth date in Part 3. |
| A photo | The EEOC says employers should not ask for a photograph before an offer is made and accepted | Take the badge photo after hire |
| Convictions | The EEOC recommends not asking about convictions on applications (guidance of April 25, 2012), and several states bar it | Ask in Part 5, after the offer |
| Alcohol tests | The EEOC treats an alcohol test as a medical exam, which must wait until after an offer. A test for illegal drugs is not a medical exam. | Test after the offer, in Part 6 |
| Form I-9 documents | USCIS says you may not ask someone who has not accepted a job offer to complete Section 1 of Form I-9 (M-274, updated April 2, 2025) | Ask whether the applicant can provide proof if hired. The new hire completes Section 1 no later than the first day of work. |

The physical tasks question follows the EEOC's rule exactly. You may state the physical requirements of a job and ask whether an applicant can meet them. You may not use a check box for "with" or "without" accommodation, because that forces the applicant to disclose a need for one. You may also ask about required licenses and certificates, and about current illegal drug use.

After the offer, you may ask medical questions or require a medical exam, but every new hire in the same job must get the same questions. Keep medical information in a separate medical file, never in the driver file.

One federal shift happened in 2026. On June 9, 2026, the Justice Department announced an opinion from its Office of Legal Counsel telling the EEOC that its disparate-impact guidelines under Title VII are unconstitutional. The announcement names criminal background checks among the practices employers may use if they are reasonable, useful, or serve a valid business purpose. It is a Justice Department opinion, not a court ruling. The EEOC's 2012 guidance on conviction records is still posted as of September 2026, and the state laws below still apply.

## State rules on conviction questions and background report notices

Many states and cities limit when you may ask about criminal records. Three examples, current as of September 2026:

| State | When you may ask about convictions | Exceptions and extra steps |
|---|---|---|
| California (Government Code 12952) | Employers with five or more employees: not on the application and not until after a conditional offer | Arrests without a conviction, diversion programs, and sealed or dismissed convictions are off limits. Before rejecting someone over a conviction, do an individualized assessment, send written notice with the report, and allow at least 5 business days to respond. The law does not apply where another law requires a criminal background check. |
| Washington (RCW 49.94.010) | Not on the application and not until you find the applicant otherwise qualified and make a conditional offer. The offer step applies to employers with 15 or more employees since July 1, 2026, and to smaller employers starting January 1, 2027. | No "no felons" job ads and no automatic exclusions. Under the same dates, hold the job open at least 2 business days so the person can explain the record. The law does not apply to jobs with unsupervised access to children under 18 or to vulnerable adults as chapter 74.34 RCW defines them, which can include a driver who rides alone with those riders. |
| Minnesota (Statutes 364.021) | Not until the applicant is selected for an interview, or before a conditional offer if there is no interview | You may tell applicants that a law or your policy disqualifies a particular criminal history. The law does not apply to employers with a legal duty to run a background check. |

Two of the same states add rules for the background report itself:

- **California.** Under the state's own consumer report law, a report with information on character, reputation, personal traits, or way of life gathered "through any means" is an investigative consumer report (Civil Code 1786.2). Its notice must also stand alone. It must name the screening company with its address, phone, and website, describe the nature and scope of the check, and include a summary of Civil Code 1786.22, which covers how the applicant can see the file. You must also offer a box to check for a copy, on the notice or a separate consent form. If the applicant checks it, the copy goes out within 3 business days (Civil Code 1786.16).
- **Minnesota.** The notice must be in writing, come before the report, and be included in or accompany the written application, so Minnesota employers hand it out with Part 1. It must tell the applicant they may ask for more information on the nature of the report, and it must include a box to check for a free copy, which the screening company sends within 24 hours of sending you the report (Statutes 13C.02).

Put each state's items on their own sheet for applicants in that state, never on Part 2. In 2019 the federal appeals court whose region includes California and Washington held that adding state notices to the federal notice breaks the stand-alone rule, and that the same form broke California's rule too (Gilberg v. California Check Cashing Stores). Ask your screening company for its California and Minnesota forms.

Minnesota also allows drug and alcohol testing of job applicants only after a job offer, only under a written testing policy, and only when every applicant offered the same job gets the same test (Statutes 181.951). Part 6 follows that order for every state. For the policy itself, see the [drug and alcohol policy template](https://nemtguide.com/templates/nemt-drug-and-alcohol-policy/).

## The Medicaid driver rules this form collects

Section 1902(a)(87) of the Social Security Act, added by the Consolidated Appropriations Act, 2021, requires every state Medicaid plan to make sure, at a minimum, that for each NEMT provider and driver it pays:

1. The provider and driver are not excluded from federal health care programs or listed on the HHS OIG exclusion list. Part 7 records those searches.
2. The driver has a valid driver's license. Parts 1 and 4 cover it.
3. The provider has a process to address any violation of a state drug law. Parts 5 and 6 are part of that process.
4. The provider has a process to disclose each driver's driving history, including traffic violations, to the state Medicaid program. Parts 4 and 5 give you the record and the driver's consent.

Public transit authorities are exempt. CMS says federal Medicaid law sets no other basic driver standards (Medicaid Transportation Coverage Guide, SMD 23-006, September 28, 2023), so states and brokers set the rest.

HHS OIG says the exclusion database can confirm a possible match with the person's Social Security number. That is one reason to collect the number in Part 3, where it stays locked.

Broker rules are what the company boxes in Parts 1 and 5 are for. Examples as of September 2026:

| Rule | MTM Health standard agreement (January 1, 2023) | MTM Health Virginia handbook (May 2026) |
|---|---|---|
| Minimum age and experience | 21 | 21, with two years of driving experience |
| Language | Read, write, and communicate effectively in English | |
| Driving record | 3 years, pulled yearly. No more than two at-fault moving violations and no more than one at-fault accident with injury or damage in 36 months. | No more than two chargeable accidents or moving violations in 3 years, DMV points not below minus 2, no suspension or revocation for moving violations in 5 years |
| Criminal record | No sexual or violent crime conviction. A felony in the last 7 years needs the approval of MTM's client. No substance abuse conviction in 7 years. No work release, probation, parole, or pending charge that would disqualify. | No barrier crimes under Virginia law. Criminal background and sex offender registry checks before transporting. |
| Drugs and alcohol | Screening before hire, after accidents, on suspicion, and at random. No treatment and no positive test in the last 5 years. | |
| Reporting | Tell MTM immediately of any criminal investigation or charge against a driver, and of any conviction for a crime against a person, an alcohol-related driving offense, or a crime of moral turpitude | |

MTM's agreement presumes a driver was at fault in an accident unless shown otherwise, and it wants police reports to prove a no-fault accident. Ask about accidents in Part 5 and keep those reports. For the full list of state rules, see [NEMT driver requirements](https://nemtguide.com/guides/nemt-driver-requirements/) and can a felon be a NEMT driver.

## If a report leads you to turn someone down

The Fair Credit Reporting Act sets two notices around any decision based even partly on a background report.

1. **Before you decide.** Give the applicant a copy of the report and the CFPB's "A Summary of Your Rights Under the Fair Credit Reporting Act" ([15 U.S.C. 1681b(b)(3)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section1681b&num=0&edition=prelim)). Your screening company should supply the summary.
2. **Wait.** The FTC says this step gives the person a chance to review the report and tell you if it is wrong. Federal law sets no number of days. California requires at least 5 business days when the concern is a conviction. Washington requires holding the job open at least 2 business days, for employers with 15 or more employees since July 1, 2026 and for smaller employers starting January 1, 2027.
3. **After you decide.** Send an adverse action notice, orally, in writing, or electronically. It gives the screening company's name, address, and phone number, says the company did not make the decision and cannot give the reasons, and explains the right to dispute the report and to get a free copy within 60 days ([15 U.S.C. 1681m](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section1681m&num=0&edition=prelim)).

Record both dates in Part 7. Sending them the same day as the decision defeats the purpose of the first notice.

## How long to keep applications and reports

| Record | How long | Rule |
|---|---|---|
| Applications and hiring records, hired or not, with 15 or more employees | 1 year from the date made or the hiring decision, whichever is later | [29 CFR 1602.14](https://www.ecfr.gov/current/title-29/section-1602.14) |
| All records tied to a discrimination charge | Until the charge or lawsuit is resolved | 29 CFR 1602.14 |
| Applications and personnel records in California | 4 years from when created or received, or from the hiring decision | [Government Code 12946](https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=GOV&sectionNum=12946) |
| Hired drivers' files | As long as your longest broker or state rule | MTM Health's standard agreement asks for full records of your operations for 10 years |
| Background reports and anything taken from them | Only as long as needed, then destroyed | [16 CFR 682.3](https://www.ecfr.gov/current/title-16/section-682.3): burn, pulverize, or shred paper, and destroy or erase electronic files so they cannot be read or rebuilt |

The federal 1-year rule starts at 15 employees, the size at which the federal laws against race, sex, and disability discrimination apply. A smaller company loses nothing by keeping applications a year too. For every record type in one place, see NEMT record retention.

## Frequently asked questions

### Can the background check consent go on the NEMT driver application?

No. The Fair Credit Reporting Act requires the notice that you may get a background report to be in a document that consists solely of that notice, given before you order the report (15 U.S.C. 1681b(b)(2)). The FTC says it cannot be part of an employment application. The applicant's signed permission may go on the same page as the notice.

### Can I ask about criminal records on a NEMT driver application?

Federal law does not ban the question, but the EEOC recommends leaving convictions off job applications, and several states bar it. California employers with five or more employees must wait until after a conditional offer. Washington bars it until a conditional offer, for employers with 15 or more employees now and for smaller ones from January 1, 2027, except for jobs with unsupervised access to children or vulnerable adults. Minnesota waits until an interview. Ask after the offer, using your broker's list of disqualifying offenses.

### Can I ask a driver applicant for their date of birth?

Ask whether the applicant meets your minimum age instead. MTM Health's standard agreement requires drivers and attendants to be at least 21, and its Virginia handbook adds two years of driving experience. The EEOC says age is irrelevant to whether a person is qualified and that age questions can be used as evidence of discrimination. Collect the birth date after the offer, for the background check.

### Do I need written permission to pull a driver's driving record?

Yes, in most cases. If a screening company pulls it, the Fair Credit Reporting Act steps apply: the stand-alone notice and written permission. If you request it from the state motor vehicle agency, the federal Driver's Privacy Protection Act lets the state release it to a requester who shows the driver's written consent (18 U.S.C. 2721(b)(13)). Your state agency may also have its own request form.

### What do I have to do before rejecting a driver over a background check?

Before you decide, give the applicant a copy of the report and "A Summary of Your Rights Under the Fair Credit Reporting Act," and give them time to point out errors (15 U.S.C. 1681b(b)(3)). After you decide, send an adverse action notice with the screening company's name, address, and phone number, a statement that it did not make the decision, and the right to dispute the report and get a free copy within 60 days.

### How long do I keep NEMT driver applications?

With 15 or more employees, keep every application, including those from people you did not hire, for 1 year from the date it was made or the hiring decision, whichever is later (29 CFR 1602.14). If a discrimination charge is filed, keep the records until it is resolved. California requires 4 years (Government Code 12946). Hired drivers' files follow your broker contract. MTM Health's standard agreement asks for full records of your operations for 10 years.

## Official resources

- [FTC: What employers must do before and after a background check](https://www.ftc.gov/business-guidance/resources/using-consumer-reports-what-employers-need-know)
- [EEOC and FTC: Background Checks, What Employers Need to Know](https://www.eeoc.gov/laws/guidance/background-checks-what-employers-need-know)
- [Federal Register: CFPB technical corrections of August 25, 2023, with the current model "A Summary of Your Rights Under the Fair Credit Reporting Act"](https://www.federalregister.gov/documents/2023/08/25/2023-18240/agency-contact-information-technical-corrections)
- [HHS OIG: Search the exclusion list (LEIE)](https://exclusions.oig.hhs.gov/)
- [SAM.gov: Search federal exclusions](https://sam.gov/content/exclusions)
- [U.S. Department of Justice: National Sex Offender Public Website](https://www.nsopw.gov/)
- [USCIS: Form I-9, Employment Eligibility Verification](https://www.uscis.gov/i-9)
- [California Civil Rights Department: Fair Chance Act](https://calcivilrights.ca.gov/fair-chance-act/)