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.Format: (000) 000-0000.
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

Other
Type a question
Type a question
Type a question
Type a question
Type a question

Select That Applies (Professional Credentials)

Other
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:
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
Date

MonthDayYear
Date
Should be Empty: