Drive With Us – Independent Courier Application

Section 1 – Contact information

Full legal name Preferred name (if different) (optional) Mobile phone number 10-digit US number Email address City and ZIP code where you live

Are you at least 21 years old? Requirement: 21 or older Yes No

Which market are you applying for?

Section 2 – Vehicle

Vehicle type you would use Sedan SUV Minivan Cargo van

Vehicle year Vehicle make (e.g., Toyota) Vehicle model (e.g., Corolla) Approximate fuel economy (combined MPG), if known (optional)

Is the vehicle registered in your name? Yes No – registered to a family member No – other

Can you provide a PAPER copy of your current vehicle registration (not the windshield sticker)? Yes, I have it now I can get a copy from my state DMV / Secretary of State No

Is your vehicle rated under 10,000 lbs GVWR? GVWR (Gross Vehicle Weight Rating) is printed on the sticker inside the driver's door jamb. Sedans, minivans, SUVs and cargo vans are usually under 10,000 lbs; larger trucks don't qualify. Yes, under 10,000 lbs GVWR No, 10,000 lbs GVWR or more Not sure

Section 3 – Insurance

Which best describes your current auto insurance? Active personal auto policy in my name Active commercial auto policy Listed on someone else's policy No current auto insurance

Can you provide proof of auto liability insurance (declarations page or ID card)? Yes No Not sure

Section 4 – Driver's license & driving record

State that issued your driver's license How many years of driving experience do you have (years holding a valid driver's license)? Requirement: at least 4 years of driving experience

Number of moving violations (tickets) in the last 3 years 0 1 2 3 or more

Number of at-fault accidents in the last 3 years 0 1 2 or more

In the last 7 years, have you had any of the following on your driving record? (select all that apply) OWI/DUI Reckless driving License suspension or revocation Leaving the scene of an accident None of these

If you selected anything above, you may briefly explain (optional) (optional)

Section 5 – Background check & MVR

This acknowledgment is not a background check authorization. Checkr will send you its own disclosure and authorization to review and sign before any report is run.

Are you willing to complete a background check and motor vehicle record (MVR) check through Checkr? Yes No

Checkr acknowledgment I understand that if I move forward, I will be asked to review and electronically sign a separate background check and motor vehicle record (MVR) disclosure and authorization from Checkr, Inc. No report will be requested until I have signed that authorization. Results would be used to qualify me for independent contractor courier routes, including review by the customers whose routes I may accept, and I may request a copy of any report.

Section 6 – Availability, coverage area & STAT responsiveness

Which areas within your market can you cover?

When a STAT (urgent) request comes in during a window you've marked available, how quickly can you usually accept or decline it? Within 5 minutes 5–15 minutes 15–30 minutes More than 30 minutes

Once you accept a STAT request, how quickly could you reach a pickup in your market? Under 15 minutes 15–30 minutes 30–45 minutes 45–60 minutes More than 60 minutes

Are you able to take same-day, on-demand calls (not scheduled in advance)? Yes, regularly Sometimes No – scheduled routes only

Roughly how many days per week would you expect to be available for routes? (optional) 1–2 3–4 5 or more It varies

Section 7 – Experience & physical requirements

Medical, lab, or pharmacy courier experience None Less than 1 year 1–3 years More than 3 years

Briefly describe any medical, specimen, or pharmacy delivery experience (optional)

How familiar are you with HIPAA (patient privacy) requirements? Completed HIPAA training in the last 2 years Familiar, but no formal training Not familiar

Have you handled chain-of-custody or specimen transport (logs, scans, temperature control)? Yes Some exposure No

Can you repeatedly lift and carry totes or packages weighing up to 50 lbs? Yes No

Your smartphone type iPhone (iOS) Android

Are you comfortable using a smartphone app for scanning, signatures, and photo proof of delivery? Yes Somewhat No

Section 8 – Contractor acknowledgments & certification

Please confirm you understand the following (select all) This is a 1099 independent contractor opportunity, not employment I provide my own vehicle, fuel, maintenance, phone, and pay my own taxes I may accept or decline routes and may work for other companies

Anything else you'd like us to know? (optional)

I certify the information I provided is true and complete to the best of my knowledge. I certify