Caregiver Registration Questionnaire

CAREGIVER CONTRACTOR APPLICATION
I acknowledge and accept that my role will be as an independent contractor, not as an employee of the company.

AcceptReject
PLEASE EXIT THE FORM. YOU DO NOT QUALIFY AS A POTENTIAL CAREGIVER.
In compliance with the State of Alabama, we conduct a comprehensive background screening. Have you EVER been charged or convicted of ANY criminal offense?*

YesNo
Thank you for letting us know. Please provide some details and information that may be helpful in our decision.
Be Ready to complete the Registration

To expedite your registration process, please ensure you have the following documents and information readily available:
- Driver’s License
- Social Security Card
- Proof of Car Insurance

Skills/Qualifications:

What skills do you have that will help you as a caregiver?
Have you ever worked as a Caregiver, sitter or companion?*

YesNo
Skills*
List any relevant skills
Qualifications*
List any relevant certifications or qualifications

References:

We'll send a verification form via email to your references. They will have 3 days to complete the form. Please inform them to expect the email.
#1 Name*
Relationship1*
Cell Phone1*
Email for Reference #1*
example@example.com
#2 Name*
Relationship2*
Cell Phone2*
Email for Reference #2*
example@example.com
#3 Name
Relationship3
Cell Phone3
Email for Reference #3
example@example.com
#4 Name
Relationship4
Cell Phone4
Email for Reference #4
example@example.com

Background Check Information
As part of our dedication to ensuring the best for our clients, it is our responsibility to conduct a thorough background check. This process encompasses both a criminal background check and reaching out to your provided references. Initially, we will attempt to contact your references via email, so it may be beneficial for you to inform them beforehand. Should we not receive a response via email, we will proceed with a phone call. We eagerly anticipate welcoming you to the COMPANY NAME community.
Please upload a copy of the front and back of your Driver's License*

Cancelof
Please upload a copy of the front and back of your Social Security.*

Cancelof
If you want transportation to be one of your services, please upload a copy of your car insurance proof of insurance.

Cancelof
If you have any certifications you would like us to know about, please upload them here.

Cancelof

Additional information:

This information is optional.
Resume

Cancelof
Cover Letter

Cancelof
Send Application:
By clicking the submit button below, I confirm that all information provided in this questionnaire is honest and complete. I understand that providing false information, omitting details, or misrepresenting facts may lead to the rejection of my registration. In joining, I agree to follow the company's rules and regulations. I acknowledge that my registration and Bio may be terminated, with or without cause, and with or without notice, at any time, either at my discretion or at the company's. I also understand that the company reserves the right to change the terms and conditions of my registration, with or without cause, and with or without notice, at any time.
Today's Date

MonthDayYear
Date
To sign the application, please type in your name.*
Please verify that you are human*
The next step is to arrange a video chat with our company administrator. We will reach out soon to schedule this.
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CAREGIVER CONTRACTOR APPLICATION