Independent Contractor Registration
Compassionate Services At Home Office Number: 561-805-1222 E-mail: INFO@ASAPCOMPANIONS.COM
Full Name:
First Name
Last Name
Birth Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number:
Please enter area code first.
Format: (000) 000-0000.
Email:
example@example.com
Home Address:
Desired Hourly Pay:
*
EXPERIENCE & SKILLS
How many years of experience do you have in companion care or caregiving?
Please list any certifications (CNA, HHA, CPR, First Aid, etc.)
If you are a certified Home Health Aide (HHA), please indicate the length of your training course:
Please Select
40 Hour Course
75 Hour Course
EMPLOYMENT HISTORY / REFERENCES
Employer/Agency:
Dates:
Responsibilities:
Employer/Agency:
Dates:
Responsibilities:
Professional Reference - Full Name:
Professional Reference - Telephone Number:
Professional Reference - Relationship:
Professional Reference - Full Name:
Professional Reference - Telephone Number:
Professional Reference - Relationship:
AVAILABILITY
How many days per week are you available?
Preferred Shift:
Please Select
AM
PM
OVERNIGHTS
MISCELLANEOUS
Languages Spoken:
Have you ever been arrested, charged with, or convicted of any criminal offense, including but not limited to felonies, misdemeanors, or any offense involving violence, abuse, theft, drugs, or fraud?
Please Select
YES
NO
If yes, please provide Type of Offense, County, and State below.
If Yes, please provide the date(s), nature of the offense(s), the jurisdiction (city/state), and the final disposition (e.g., dismissed, convicted, deferred adjudication, etc.):
Signature:
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