Contractor Application
|
|
Please fill in all fields to the best of your ability. Incomplete applications and phone calls will not be accepted. Please press submit at the bottom of the form to send your application to us.
|
| Applicant Information |
| First Name: |
|
| Last Name: |
|
| Address Street 1: |
|
| Address Street 2: |
|
| City: |
|
| Zip Code: |
(5 digits) |
| State: |
|
| Education History |
| Degree/Specialty: |
|
| License #: |
|
| Contact Information |
| Daytime Phone: |
|
| Evening Phone: |
|
| Email: |
|
| Personal Informatin |
| Social Security # |
|
| Are you 18 yrs. of age or older? |
Yes |
| Driver's License # and State |
|
| Previous Employment |
| Employer |
Salary |
| Title |
|
| Dates Employed: |
TO |
| Contact Information |
|
| Primary Duties |
|
|
|
|
|
|
I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts represents grounds for elimination from consideration or termination after contracted if discovered at a later date. I authorize Certain Care LLC to investigate, without liability, all statements contained in this application and supporting materials. I further authorize references and former employers, without liability, to make full response to any inquiries in connection with this application. I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of contracts. I understand that this application is NOT an offer of contractual work, and that an offer of contracts, if tendered, does NOT constitute a contract for continued, guranteed engagements. I understand that contractors of Certain Care LLC serve at-will, and the contractor relationship may be severed at any time by either party, for any or no reason, other than a reason prohibited by law. I understand that if contracted on a temporary basis, I would be paid for hours worked only, and would be inelgible for benefits including, but not limited to, health insurance, paid time off and unemployment per the contractor agreement. I authorize Certain Care LLC to verify
my background and employment history. |
|
