Independent Contractor Information Form

Independent Contractor Information Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Work Information
Job Title/ Position*
Areas of Expertise*
Availability (Days/ Times)*
Preferred Start Date*

MonthDayYear
Date
Licenses and Certifications
Professional License Number (if applicable)
Expiration Date

MonthDayYear
Date
Certifications*
License Uploads

Cancelof
Insurance Information
Professional Liability Insurance Carrier:
Policy Number:
Expiration Date

MonthDayYear
Date
Upload your license

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Tax Information
Social Security Number*
(for tax and Level 2 Background Screening purposes)
Completed W-9 Form

Cancelof
References
Reference #1 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Reference #2 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Acknowledgment
I acknowledge that I am providing my services as an independent contractor and understand that I am not an employee of M.D. Home Health, LLC. I understand that I am responsible for my own taxes and insurance, and that I will not receive benefits such as health insurance or paid time off. I also consent to a Level 2 Background Screening as part of the onboarding process.
Signature*

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Should be Empty:

Work Information