Contractor Registration

Name:    

Address: 

SSN (Optional ): Phone: Alt:

Position Desired:

Days and hours you are available to work

Day                    Hours                    AM/PM

Monday                       AM    PM

Tuesday                       AM    PM

Wednesday                  AM    PM

Thursday                      AM    PM

Friday                          AM    PM

Saturday                      AM    PM

Sunday                        AM    PM

Can you live onsite?         Yes       No

Do you have reliable transportation & Insurance ?         Yes        ; ; ; ; ; ; ; ; ; ; ; ; ; No

Can you relocate to another city or state ?  Yes         ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; No

Are you 18?           Yes         No

Do you smoke?      Yes       No

Do you have any experience working with children or the elderly?        Yes      No

If Yes, Please specify

Have you ever been convicted of a crime?       Yes       No
If Yes, please explain:

Do you use any drugs?         Yes      No

Previous employment

Company Name Supervisor
Phone # Position
Start Date End Date Starting pay Ending pay
Reason for leaving Can we contact this Company?      Yes    No

Company Name Supervisor
Phone # Position
Start Date End Date Starting pay Ending pay
Reason for leaving Can we contact this Company?    Yes    No

Company Name Supervisor
Phone # Position
Start Date End Date Starting pay Ending pay
Reason for leaving Can we contact this Company?      Yes     No

Personal references

Name Relationship

Years known Phone #

Name Relationship

Years known Phone #

Name Relationship

Years known Phone #

How did you find out about us? Friend his/her Name

Does he or she work for us?        Yes     No

If you saw an Ad tell us where you saw it

General Questions

Why would one of our clients pick you ?

Questions for elderly care and Child care Contractors

What would you do in case of emergency?

What would you do if a baby starts crying?

Do you have CPR certification?       Yes     No

Do you have Medicaid Certification?      Yes      No

List any special skills that you have.

Notes: