H-town Driver Application HTown Drivers Last Name * Have you used other Names? * Yes I have used other Name No Other Name Other First Name(s) Other Middle Name(s) Other Last Name(s) Cell Phone * +1 Please make sure that your number starts with +1 Residence Phone (If Applicable) Business Phone (If Applicable) Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Address Which area/s do you prefer to work in? No Preference (all areas) Houston METRO Area (inside loop) Woodlands / Conroe Humble / Kingwood Port area / Baytown / Beaumont Clear Lake / Nasa/ Galveston Alvin / Pearland Stanford / Sugar Land Katy / Warton Cypress / Greenspoint / Hempstead How do you wish to be paid out? * Select OnePayPalVenmoCash AppZelle Payout Account Name * Diver License Number Driver Licenses Expiration Date Tax ID Number (SSN/EIN) * Date of Birth * * Male Female Birth City * Birth State * Have You lived out of the State of Texas * Yes No States Other Than Texas Other than Texas, List all other states you have lived in (subject to background check) Are you eligible to work in the US? * Yes No Ethnicity(must accompany race) Hispanic Non-Hispanic Do not wish to disclose Race White Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Do not wish to Disclose Vehicle 1 Type * Select OneSedan (4) PassengersSUV (4) PassengersSUV (7) PassengersVAN (10) PassengersVan (15) Passengers Vehicle 1 Make * Vehicle 1 Model * Vehicle 1 Year * Vehicle 1 License Plate # * Vehicle 1 Color * Vehicle 2 Type Select OneSedan (4) PassengersSUV (4) PassengersSUV (7) PassengersVAN (10) PassengersVan (15) Passengers Vehicle 2 Make Vehicle 2 Model Vehicle 2 Year Vehicle 2 License Plate # Vehicle 2 Color Load Copy of Drivers License Front Drop a file here or click to upload Choose File Maximum file size: 516MB Load Copy of Drivers License back Drop a file here or click to upload Choose File Maximum file size: 516MB Load Copy of Insurance Card Vehicle 1 Drop a file here or click to upload Choose File Maximum file size: 516MB Load Copy of Car registration Sticker Vehicle 1 Drop a file here or click to upload Choose File Maximum file size: 516MB Load Copy of Insurance Card Vehicle 2 Drop a file here or click to upload Choose File Maximum file size: 516MB Load Copy of Car registration Sticker Vehicle 2 Drop a file here or click to upload Choose File Maximum file size: 516MB Select All * By signing this Background Checks Attestation and Release Form, I verify that the information on this form contains no willful misrepresentation, and that the information given is true and complete to the best of my knowledge. * I give my consent for the contractor and its agent(s) to obtain criminal history information related to my application for employment, volunteer status, or contracted services. Any such information will be used solely for employment, volunteer status, or contracted services-related considerations and not for any other purpose. I understand that the information released is for official use and may be disclosed to third parties as necessary in the fulfillment of official * I authorize, consent, and grant permission for the contractor and its agent(s) to release any and all information regarding my criminal history to the Texas Workforce Commission. Any such information will be used solely for the purpose of determining whether I may provide services or interact with VR customers. I waive any and all claims I may have with respect to providing such information. I understand that the contractor, agent(s), and TWC are not responsible for the accuracy or completeness of the information contained in such reports. I release the contractor, its agents, and TWC from any and all liability, claims, and lawsuits with respect to the information obtained from any of all sources used by the contractor and its agent(s). I understand that TWC may contact others and, at any time, seek proof of any information contained herein. I understand that any willful misrepresentation or failure to provide identifying information within the stated time limit is a cause for denial or revocation of the approval to provide services to TWC, directly or indirectly. I also understand that this authorization is a continuing authorization and will remain valid until such time as I inform the contractor in writing that I revoke this authorization. Signature * Clear Admin Status PendingActiveInactive Application Results Application ApprovedApplication Rejected Termnation Reason N/AVoluntaryInvolentary Type Driver UnknownPriorityPicky DriverUse Only if nobody Wants the jobDo Not use this DriverDNU Notify Applicant Send Approved Email Application Not Approved -Car Application Not Approved – Criminal Background My Notes about the driver If you are human, leave this field blank. Submit Δ
