Revised 10/2017
INDEPENDENT CONTRACTOR APPLICATION
POSITION APPLYING FOR: DSP Home Health Aide, 75hrs. CNA
We are an Equal Employment Opportunity and Non-Discriminating Employer.
PERSONAL INFORMATION
______________________________________________________________________________________________
Legal name: First Last Middle Initial
______________________________________________________________________________________________
Address: Street City State Zip code
Home Telephone: _______________________________ Other Telephone: _____________________________
E-mail: _______________________________________ S.S. # - -
Driver’s License #: ____________________________________________ State: ________________________
Are you a citizen of the U.S? Yes No If not, are you authorized to work in the U.S.? Yes No
Have you ever been convicted of a felony? Yes No
If yes, please explain: _________________________________________________________________________
_____________________________________________________________________________________________
Are you currently charged, excluded, suspended, debarred or otherwise ineligible to participate in federal
health care programs, including Medicare and Medicaid? Yes No
Have you been convicted of a criminal offense related to the provision of health care items or services and
have not been reinstated in the federal health programs? Yes No
Are you at least 18 years old? Yes No
POSITION INFORMATION
Independent Contractor available schedule: Mon Tue Wed Thurs Fri Sat Sun
Hours Available: From: __________ to __________
How many hours are you willing to work? Less than 20hrs. per week More than 20hrs. per week
What shift are you willing to work? AM PM Weekends
***Please note that you are applying for an Independent Contractor 1099 position***
Revised 10/2017
WORK HISTORY (Most recent first)
1. Job Title: Duties:
Employer:
Dates of Employment (month / year)
From: To:
Starting Salary: Ending Salary: Full Time Part Time Temp
Employer’s Address:
Supervisor: May we contact? Yes No Phone:
Reason for Leaving:
REFERENCE:
2. Job Title: Duties:
Employer:
Dates of Employment (month / year)
From: To:
Starting Salary: Ending Salary: Full Time Part Time Temp
Employer’s Address:
Supervisor: May we contact? Yes No Phone:
Reason for Leaving:
REFERENCE:
3. Job Title: Duties:
Employer:
Dates of Employment (month / year)
From: To:
Starting Salary: Ending Salary: Full Time Part Time Temp
Employer’s Address:
Supervisor: May we contact? Yes No Phone:
Reason for Leaving:
REFERENCE:
I have at least one year of experience working with children and/or adults with
developmental disabilities, in a medical, psychiatric, nursing or child care setting.
***Please note that you are applying for an Independent Contractor 1099 position***
Revised 10/2017
EDUCATION
Dates Degree Subjects Did you
Type of school Name and Location
Attended Received Studied graduate?
High School
College /
University
Graduate
School
Tech School
Other
Special courses, trainings or experience acquired, including military experience: ________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
SKILLS
Clerical / Office skills
Yes No If so, please specify:
Computer skills
Languages English Spanish Other: _________________________
Other skills
________________________________________________________________________________________________
CERTIFICATION & AUTHORIZATION
I hereby certify that all statements made in this application are true and correct to the best of my
knowledge. I understand that any misrepresentations or omissions of facts in this application are grounds
for disqualification from further consideration or for dismissal from Sub-Contractor employment.
I authorize the company to inquire into my educational, professional and past employment history
references as needed to research my qualifications for this position.
If hired, I agree to conform to the rules, regulations and policies of the company. I understand that I will be
a sub-contractor “at will” and either the company or I may terminate my sub-contractor relationship at any
time for any reason not in violation of law.
I am aware that an Independent Contractor employment is contingent upon the satisfactory results
of reference checks, and both Local Law Enforcements and Federal Bureau of Investigation
Background Screening Checks.
I hereby acknowledge that I have read and fully understand the forgoing and seek a Sub-Contractor
employment under these conditions.
_____________________________________________ ____________________
Signature of Applicant Date
***Please note that you are applying for an Independent Contractor 1099 position***
