M_Group_Alabama_Job_Application_Jotform

Independent Contractor Job Application
Full Legal Name*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Address on Government ID if different*
Email*
example@example.com
Social Security Number*
Are you open to traveling outside your area? If yes, how far (miles or counties)*
Type a question*

Crisis Prevention InterventionsdeescalationCpr/First aidmedication Pass certifiedHands on Behavioral trainingOther
Type a question*
Type a question
Type a question
Type a question
Type a question

Select That Applies (Professional Credentials)*

RBTCNALPNRNSocial WorkerTherapistCounselorOther
Describe your experience in this field*
Please list jobs where you worked with children, families, or people who needed help or support. Employer / Job Title / Dates Worked / What did you do:
Employer / Job Title / Dates Worked / What did you do:*
Are you familiar with HIPAA If no are you willing to follow HIPAA rules*
Are you familiar with DHR If no are you willing to follow DHR rules*

Independent Contractor Acknowledgment. I understand this is a 1099 independent contractor position and I am responsible for my own taxes:

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Professional JOB References Reference 1 (Name / Relationship / Phone):
Reference 1 (Name/ Relationship/ Phone)
Reference 2 (Name / Relationship / Phone)
Reference 3 Optional
Job Knowledge & Scenario Questions
1 If a client becomes upset or aggressive what would you do
2 How do you build trust while staying professional
3 Tell us about a difficult situation with a client and how you handled it
4 How do you keep client information private
Applicant Certification & Signature
Applicant Signature

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Date

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Date
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