Customer Details:
We're excited to help your simplify caregiver recruiting and grow your agency! This page is to sign up for recurring monthly plans. Once your form is completed, you'll receive your full onboarding packet and a welcome from your account manager. Most customers are fully onboarded within 2-3 business days.
Company Name
*
First Name
*
Last Name
*
Full Name
*
First Name
Last Name
Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
How did you hear about us?
*
How did you hear about us?
Please Select
Word of Mouth
Google
LinkedIn
Facebook
Conference
Online Webinar
Referral
Other (Please specify...)
Other
Who referred you?
*
What conference?
What webinar?
What type of appointment will Carework be booking for you after we screen each applicant?
Interview Bookings
Orientation Bookings
Monthly Subscription Deposit
*
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( X )
Basic
Hire Carework to help you get 5-10 qualified caregivers in the door per month
$
1,300.00
for each
month
Advanced
Hire Carework to help you get 11-16 qualified caregivers in the door per month
$
2,100.00
for each
month
Executive
Hire Carework to help you get 17-22 qualified caregivers in the door per month
$
3,100.00
for each
month
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
How would you like to pay for your subscription fees moving forward? (your deposit today is charged to the card you've entered and you are not charged a processing fee)
*
Carework will charge the card listed here and add a 2.9% processing fee
Carework will call you to setup fee-less ACH payment
I have read and agreed to the terms and conditions
*
I agree
I understand I am agreeing to an initial six-month contract, agreeing to be charged every month for six months, and that I cannot cancel or "pause" during that time
*
I agree
Digital Signature for attached PDF Contract and Other Terms On This Page
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