[EXTERNAL] Independent Contractors Pre-Engagement Questionnaire and Scheduling Availability (Step 1)

  • Pre-Engagement Questionnaire and Scheduling Availability

  • Date*
     - -
  • Which role are you applying for?*

  • Eligibility

  • Are you at least 18 years of age?*
  • Do you have reliable transportation to arrive on time for scheduled shifts?*

  • If you answered ‘No’ to any of the required eligibility questions (age or transportation), you are not eligible for a position at this time.

  • Location of interest in Albuquerque

  • Scheduling Availability Request

  • Call me for work on my days off?*
  • Call / Text  me before 8:00am or after 8:00pm?*
  • I am available for:*

  •  

    Independent Contractor:

    Day (9:15am - 5:00pm)

    Night (5:00pm - 10:00pm)

  • Rows
  • Rows
  • Are you interested in shifts outside of your availability to reach your desired number of hours?*

  • Availability & Practice Commitment

  • Are you able to work a minimum of 2 shifts per week to maintain contractor status?*

  • I have acknowledged and fully understand that I will be required to work when needed based on the information below. I understand that the below information is merely a request for the times I would prefer to be scheduled and we will try to follow this as much as possible.

  • Licensure Status

  • Do you hold a current New Mexico license in good standing as required for contracted work, [LMT, DOM, or Esthetician]*
  • Have you ever had your license suspended, revoked, or otherwise disciplined?*

  • Insurance

  • Do you carry professional liability and malpractice insurance as required for contracted work?*
  • Have you ever had a malpractice or professional liability claim filed against you?*

  • Professional History & Claims Disclosure

  • Have you ever been the subject of a formal board complaint, investigation, or disciplinary action?*
  • Date
     - -

  • Optional

  • Should be Empty: