Contract Application - Independent Contractor Profile

Contract Application - Independent Contractor Profile
Contract Application

**Please fill out all blanks if applicable. Thank you**
Name
Maiden
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Phone
Message Phone #

List three (3) references not related to you:

	Name	Phone #	Work	Personal
Reference # 1
Reference # 2
Reference # 3

List any experience or skills you have dealing with personal care:
Are you a CNA?

YesNo
Are you a PCA?

YesNo
**We require that you have either a C.N.A., P.C.A., or a 1 year verifiable-experience in an institutional setting.
List any college or extra training that you have received along with the dates of completion:

List the last three (3) employers/companies you worked for:

	Company	Address & Phone	Dates of Service	May we contact? Y/N
1.
2.
3.

Have you ever been convicted of a crime, other than minor traffic violations?

YesNo
Can you pass a background check?

YesNo
If no, please explain:

What hours are you available to work each day of the week? List start and end times:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Start and End times

I hereby certify that the above information is true to the best of my knowledge and understand that this application does not guarantee a contract position with Elite Senior Care. I further understand that Elite Senior Care only hires contract CNA's and PCA's.
Applicant's Signature:

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Date

MonthDayYear
Date

Independent Contractor Profile

	Information
Contractor Name:
Contractor Address:
City, Zip Code
Birthday (optional)
Phone:
Alternate Phone:
Emergency Contact 1:
Phone Number:
Emergency Contact 2:
Phone Number:

Scheduled Prescriptions that we should be aware of in case of random drug test:
Any Medical Information that we should be aware in case of emergency: