<p> Registration For Contractor</p><p>All prospective contractors will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.</p><p>PERSONAL</p><p>Last Name First Middle Date</p><p>Street Address Home Phone</p><p>City, State, Zip Code Business Phone</p><p>______S.S. # email Date of Birth</p><p>Emergency contact ______Relationship ______Contact number______</p><p>What make of car ______What color______Tag #______</p><p>Have you ever applied for work with this Agency? Yes No</p><p>Are you allergic to any animal that might be a pet? _____Yes ______No</p><p>Are you allergic or prefer not to work with any person who smokes? _____Yes ______No Do you smoke____</p><p>How many hours a week are you available for work? </p><p>Are you willing to work: ______Evenings? _____Weekends? ______Live-ins?</p><p>Are you legally eligible for employment in the United States? Yes No</p><p>How did you learn of our organization? Newspaper Ad Agency employee Other</p><p>Have you completed an approved course on HIV/AIDS?____Yes____No Assistance with Self-administration of medication Yes____ No___ Current CPR Yes__ No __ (Must Provide Documentation)</p><p>Contractor App Rev: Jan 2015 Page 1 Position applying for: RN____ LPN____ CNA____ HHA_____ sitter/companion _____</p><p>License/Certification Number______Expires ______</p><p>EDUCATION:</p><p>School Name Location of School Course of Study Years Degree/Study/Diploma College: ______</p><p>Vo-Tech or Trade:</p><p>______</p><p>High School: ______Other:</p><p>______</p><p>Was your last name different from your present name during the above listed jobs? Yes No </p><p>If Yes, what was your name? </p><p>Are you currently employed? Yes No </p><p>Do you have reliable transportation? Yes No </p><p>PROFESSIONAL REFERENCES Persons who can furnish information about job performance</p><p>1. Name: Telephone: Address: </p><p>2. Name: Telephone: Address: </p><p>3. Name: Telephone: </p><p>Contractor App Rev: Jan 2015 Page 2 Address: </p><p>Employment: * List the last five years employment history with no gaps in dates, starting with the most recent employer. If you need more space, please use back of this page</p><p>1. Company Name: ______Telephone: </p><p>Address: Dates of Employment: From To </p><p>______Starting Pay ______City State Zip Code</p><p>Job Title and Describe your work: ______</p><p>Reason for leaving: ______</p><p>2. Company Name: ______Telephone: </p><p>Address: Dates of Employment: From To </p><p>______Starting Pay ______City State Zip Code</p><p>Job Title and Describe your work: ______</p><p>Reason for leaving: ______</p><p>3. Company Name: ______Telephone: </p><p>Address: Dates of Employment: From To </p><p>______Starting Pay ______City State Zip Code</p><p>Job Title and Describe your work: ______</p><p>Reason for leaving: ______</p><p>4. Company Name: ______Telephone: </p><p>Address: Dates of Employment: From To </p><p>______Starting Pay ______City State Zip Code</p><p>Contractor App Rev: Jan 2015 Page 3 Job Title and Describe your work: ______</p><p>Reason for leaving: ______</p><p>5. Company Name: ______Telephone: </p><p>Address: Dates of Employment: From To </p><p>______Starting Pay ______City State Zip Code</p><p>Job Title and Describe your work: ______</p><p>Reason for leaving: ______</p><p>6. Company Name: ______Telephone: </p><p>Address: Dates of Employment: From To </p><p>______Starting Pay ______City State Zip Code</p><p>Job Title and Describe your work: ______</p><p>Reason for leaving: ______</p><p>GENERAL</p><p>Have you ever been convicted of a crime in the past 5 years? Yes No If yes, describe in full: </p><p>CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED</p><p>List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualifications acquired from employment or other experience. Example: HHA, CNA (must have documentation) and all certifications (example CPR, assistance with self-administered medications, etc) Please provide copies of all certificates and CEU’s</p><p>Date of renewal for License </p><p>Contractor App Rev: Jan 2015 Page 4 I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL</p><p>I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former contractors and others listed above from all liability for any damage that my result from furnishing the same to the Agency.</p><p>I understand and agree that, if contracted, my association is for no definite period and may, regardless of the date of payment of my earnings, be terminated at any time for any reason, without prior notice and with or without cause.</p><p>This application for contractor shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for consideration beyond this time period shall inquire as to whether or not applications are being accepted at that time.</p><p>I, ______affirm that the above information is true, accurate and complete. I state that my driver’s license is valid and affirm that I have never had my driver’s license revoked or suspended in any state or country, that my vehicle is insured and the insurance is maintained and give CAREGIVING WITH LOVE permission to perform a Level 2 criminal background check as required by Florida State Statutes, driving record checks and other such employment checks as determined necessary by CAREGIVING WITH LOVE or required by Florida State Statutes or ACHA Regulations now and in the future.</p><p>______Signature Date</p><p>Print Name:______Rev: Jan 2015</p><p>Contractor App Rev: Jan 2015 Page 5</p>