CONTRACTOR APPLICATION

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:
Employer:

From: To:

Reason for Leaving:
REFERENCE:
Employer:

From: To:

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.
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

CONTRACTOR APPLICATION

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CONTRACTOR APPLICATION

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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.

Home Telephone: _______________________________ Other Telephone: _____________________________

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

Driver’s License #: ____________________________________________ State: ________________________

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

If yes, please explain: _________________________________________________________________________

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

WORK HISTORY (Most recent first)

1. Job Title: Duties:

Dates of Employment (month / year)

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

2. Job Title: Duties:

Dates of Employment (month / year)

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

3. Job Title: Duties:

Dates of Employment (month / year)

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

Dates Degree Subjects Did you

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

CERTIFICATION & AUTHORIZATION

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Home Telephone: ___ Other Telephone: _

Driver’s License #: ____________________ State: