Contractor Application

Registration For Contractor

All prospective contractors will receive consideration without discrimination because of race, color, creed, age, sexual orientation, natural origin or handicap.  All information provided herein will be kept confidential.






Personal

Name:



Address:


Telephone:


E-mail Address:

Emergency Contact:



Date of Birth:

Social Security Number:

Vehicle Information:



Have you ever applied for work with this Agency?

YesNo

Are you allergic to any animal that might be a pet?

YesNo

Are you allergic or prefer not to work with any person who smokes?

YesNo

Do you smoke?

YesNo

How many hours a week are you available for work?

Are you willing to work:

EveningsWeekendsLive-ins

Are you legally eligible for employment in the United States?

YesNo

How did you learn of our organization?

Newspaper AdAgency employeeOther

Have you completed an approved course on:

HIV/AIDS?

YesNo

Assistance with Self-administration of medication?

YesNo

Med Tech Certificate?

YesNo

Current CPR (Must Provide Documentation)

YesNo

Position applying for:

RNLPNCNAHHASitter/Companion

License/Certification


Education

College





Vo-Tech or Trade





High School





Other





Was your last name different from your present name during the above listed jobs?

YesNo

If Yes, what was your name?

Are you currently employed?

YesNo

Do you have reliable transportation?

YesNo

Professional References

Persons who can furnish information about job performance

Reference 1



Reference 2



Reference 3



Employment

* List the last five years employment history with no gaps in dates, starting with the most recent employer.

Company 1









Company 2









Company 3









Company 4









Company 5









Company 6









General

Have you ever been convicted of a crime in the past 5 years?

YesNo

If yes, describe in full:

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualifications acquired from employment or other experience. Example: HHA, CNA (must have documentation) and all certifications (example CPR, assistance with self-administered medications, etc) Please provide copies of all certificates and CEU’s

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former contractors and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if contracted, my association is for no definite period and may, regardless of the date of payment of my earnings, be terminated at any time for any reason, without prior notice and with or without cause.

This application for contractor shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for consideration beyond this time period shall inquire as to whether or not applications are being accepted at that time.

I affirm that the above information is true, accurate and complete. I state that my driver’s license is valid and affirm that I have never had my driver’s license revoked or suspended in any state or country, that my vehicle is insured and the insurance is maintained and give CAREGIVING WITH LOVE permission to perform a Level 2 criminal background check as required by Florida State Statutes, driving record checks and other such employment checks as determined necessary by CAREGIVING WITH LOVE or required by Florida State Statutes or ACHA Regulations now and in the future.


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