Host Home Provider
Independent Contractor Application
A background check is required of all adults living within the Host Home. If you have been convicted of a felony, please include, on a separate sheet, information that will assist KP Supports in processing your application.
Names of all other individuals (not in services) currently living in home:
If there are any individuals and services living with you, please list their initials, age, and CCB
I would like to provide a home for, and I have the accommodations for:
I certify that answers given are true and complete to the best of my knowledge.I
authorize investigation of all statements contained in this application as necessary and arriving to a decision.