RI Perinatal Doula Agency Interest Application

Application

Independent Contractor
Full Legal Name *

First Name Middle Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Check one

I am looking for Full time work I am Looking for Part time work
Completed Certified Doula Training? *

Yes No In Process
Are you a Provisional Trained Doula or Fully Certified? *

Yes No In Process
Are you a Certified Professional Doula? *

Yes No In Process
Upload a copy of your certification (RI Certification Board CPD)

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Cancel of
NPI
If you can not upload certification please leave a comment for reason
Do you currently operate as an independent practicing doula?*Business name*

Yes No
If yes, please list your business name
EIN
Upload a copy of your doula insurance

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Cancel of
How soon can you start taking clients:
What is an ideal client family to provide doula services? (can include racial/ethnic, religious preferences):
What hospitals do you prefer to provide service in attendance?:
Are you open to virtual doula services?:
Languages Spoken
Languages Spoken:

Fluently Poorly Not at all Conversational
Describe fluency in detail:
I am a U.S. Citizen or am authorized to work in the U.S.:

Yes No
Have you ever been convicted of a felony? (This does not automatically exclude you from employment )

Yes No
Do you have reliable transportation?

Yes No
Education History
High School
High School Diploma or GED program?
High School City, State
Graduated or Completed

Yes No
College
College Name
Years Attended
Focus of Study
Graduated

Yes No
Other Education
Other education:
Employment History
Most Recent Employer
Most Recent Employer Name

	Date Started	Date Ended
Dates worked for

Most Recent Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Type of work performed
Reason for Leaving
Second Most Recent Employer

Only fill out if you are working more than one job or if you own a separate business in addition to working
Second Most Recent Employer Name

	Date Started	Date Ended
Dates worked for

Second Most Recent Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Type of work performed
Reason for Leaving
References
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Reference

Professional Personal Community
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Reference

Professional Personal Community
Please review the Independent Contractor Agreement sheet. Before Hiring you will be asked to sign.
At this point in the application you are free to tell us if there is any reason we would not be able to hire you as an independent contractor.
At this point in the application you are free to tell us what makes you the perfect candidate for RI Perinatal Doula Agency, if you desire.
Hobbies, interest or special skills? (not required )
Feel Free to upload your Resume
Thank you for taking time to complete this application. We will be in contact with you shortly. We look forward to you potentially becoming part of the RI Perinatal Doula Agency

www.riperinatal.com/
Should be Empty:

Application

Education History

High School

College

Other Education

Employment History

Most Recent Employer

Second Most Recent Employer

References