Secure Partner Prequalification Form Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What Counties/Cities do you service? * How many wheelchair accessible vehicles are in your current fleet? * How many ambulatory vehicles are in your current fleet? * Are you licensed for non-emergency medical transportation? * Yes No Are your chauffeurs uniformed? * Yes No Are your vehicles clearly branded? * Yes No Do you have Workman’s Compensation Insurance? Yes No Do you have a Safety Program? Yes No Do you perform pre-employment background screenings? Yes No Thank you!
