Independent Contractor Application
Name:
Phone (cell):
Phone (home):
E-mail:
Address:
(Please include Street Address, City, State and Postal Code)
Education History
Institution
Field of Study
Years Attended
Degree Received
1.
2.
3.
Recent Work History
Please fill in the following information for your three most recent places of employment:
Employer 1:
Supervisor's name:
Supervisor's phone:
Employment dates:
Skills acquired/accomplishments:
Reason for leaving:
Employer 2:
Supervisor's name:
Supervisor's phone:
Employment dates:
Skills acquired/accomplishments:
Reason for leaving:
Caregiver skill checklist
Done within the last year?
Done within the last 5 years?
List where you had the experience:
Are you a Certified nursing assistant?
Hospice care
Incontinent care
Care for bed bound patient
Shower/bathing assist
CPR certified
Med certified
Heavy lifting (state any limitations)
Transfers
Alzheimer's care
Allergies to pets
Cooking
Wound care
Additional questions
Do you have any medical restrictions that would interfere with this type of work?
YES;
NO
Would you have any issues with providing care assistance under medical guidelines?
YES;
NO
What special qualities would you bring to this position?
Have you ever been convicted of a felony?
YES;
NO
Do you have your own car?
YES;
NO
Do you have valid car insurance?
YES;
NO
How many hours a week do you want to work?
How did you hear about this position?
Comments/Questions?
Things you should consider before you proceed with your application:
You are hired as a independent contractor, and will receive a 1099 and must pay self-employment tax.
All new Dignity Care employees are expected to work one weekend day or night if needed.
