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CONTRACTOR APPLICATION

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13 views

CONTRACTOR APPLICATION

Uploaded by

prd7kzty6s
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

Revised 10/2017

INDEPENDENT CONTRACTOR APPLICATION

POSITION APPLYING FOR:  DSP  Home Health Aide, 75hrs.  CNA

We are an Equal Employment Opportunity and Non-Discriminating Employer.

PERSONAL INFORMATION

______________________________________________________________________________________________
Legal name: First Last Middle Initial

______________________________________________________________________________________________
Address: Street City State Zip code

Home Telephone: _______________________________ Other Telephone: _____________________________

E-mail: _______________________________________ S.S. # - -

Driver’s License #: ____________________________________________ State: ________________________

Are you a citizen of the U.S?  Yes  No If not, are you authorized to work in the U.S.?  Yes  No

Have you ever been convicted of a felony?  Yes  No

If yes, please explain: _________________________________________________________________________


_____________________________________________________________________________________________

Are you currently charged, excluded, suspended, debarred or otherwise ineligible to participate in federal
health care programs, including Medicare and Medicaid?  Yes  No

Have you been convicted of a criminal offense related to the provision of health care items or services and
have not been reinstated in the federal health programs?  Yes  No

Are you at least 18 years old?  Yes  No

POSITION INFORMATION
Independent Contractor available schedule: Mon Tue Wed Thurs Fri Sat Sun
Hours Available: From: __________ to __________

How many hours are you willing to work?  Less than 20hrs. per week  More than 20hrs. per week
What shift are you willing to work? AM PM  Weekends

***Please note that you are applying for an Independent Contractor 1099 position***
Revised 10/2017

WORK HISTORY (Most recent first)

1. Job Title: Duties:

Employer:

Dates of Employment (month / year)


From: To:

Starting Salary: Ending Salary:  Full Time  Part Time  Temp


Employer’s Address:
Supervisor: May we contact?  Yes  No Phone:
Reason for Leaving:

REFERENCE:

2. Job Title: Duties:

Employer:

Dates of Employment (month / year)


From: To:

Starting Salary: Ending Salary:  Full Time  Part Time  Temp


Employer’s Address:
Supervisor: May we contact?  Yes  No Phone:
Reason for Leaving:

REFERENCE:

3. Job Title: Duties:

Employer:

Dates of Employment (month / year)


From: To:

Starting Salary: Ending Salary:  Full Time  Part Time  Temp


Employer’s Address:
Supervisor: May we contact?  Yes  No Phone:
Reason for Leaving:

REFERENCE:

 I have at least one year of experience working with children and/or adults with
developmental disabilities, in a medical, psychiatric, nursing or child care setting.

***Please note that you are applying for an Independent Contractor 1099 position***
Revised 10/2017

EDUCATION

Dates Degree Subjects Did you


Type of school Name and Location
Attended Received Studied graduate?

High School

College /
University
Graduate
School

Tech School

Other

Special courses, trainings or experience acquired, including military experience: ________________________


________________________________________________________________________________________________
________________________________________________________________________________________________

SKILLS
Clerical / Office skills
Yes No If so, please specify:
Computer skills
 
Languages  English  Spanish  Other: _________________________

Other skills

________________________________________________________________________________________________

CERTIFICATION & AUTHORIZATION


I hereby certify that all statements made in this application are true and correct to the best of my
knowledge. I understand that any misrepresentations or omissions of facts in this application are grounds
for disqualification from further consideration or for dismissal from Sub-Contractor employment.

I authorize the company to inquire into my educational, professional and past employment history
references as needed to research my qualifications for this position.

If hired, I agree to conform to the rules, regulations and policies of the company. I understand that I will be
a sub-contractor “at will” and either the company or I may terminate my sub-contractor relationship at any
time for any reason not in violation of law.

I am aware that an Independent Contractor employment is contingent upon the satisfactory results
of reference checks, and both Local Law Enforcements and Federal Bureau of Investigation
Background Screening Checks.

I hereby acknowledge that I have read and fully understand the forgoing and seek a Sub-Contractor
employment under these conditions.

_____________________________________________ ____________________
Signature of Applicant Date

***Please note that you are applying for an Independent Contractor 1099 position***

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