Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
All of our service providers are Independent Contractors. At the end of the year, we issue a 1099 tax form. Does this work for you?
Yes
No
Have you ever provided on-location or mobile services before? Do you own your own supplies?
Yes
No
What is your availability like? Please list days/times you are free to help with services. If it is just one day a week, that is fine.
Less than 10%
At least 10%, but less than 25%
At least 25%, but less than 50%
50% or more
Professional Reference - Please provide Name & Email address of one reference. If you were referred by someone that works with Primp In Home, please list their name only below.
Professional License & Certificates (State license - Cosmetology, Esthetics, Nail, Massage, CPR, etc.)
*
Do you carry Professional Liability Insurance? We do require it and ask to be listed as additional insured. A company we recommend is InsureBodyWork.com. We will need this once all your paperwork is complete. We will let you know when we need it.
Yes
No
Have you been convicted or accused of a crime in the past 10 years?
Yes
No
Our jobs are about 1.5 hours from the time we ask you to arrive until you are finished. So if we ask you to arrive at 10:00 AM to a home, the job should finish by about 11:30 AM. That is what the pay we quote for the job will be based on. Please confirm this works for you.
Please attach resume if you have one.
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Attestation and Certification:
I give my certification of the above.
I do not give my certification of the above.
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