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
Personal references
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: