Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) How did you hear about this position?

Q.) Are you a citizen of the United States? (Yes or No)

Q.) If no, are you authorized to work in the US?

Q.) Have you ever been convicted of a felony? (Yes or No)

Q.) I certify that the facts set forth in this application are true, complete, and correct to the best of my knowledge. I understand that any misrepresentations, falsifications, or omissions on this application can be grounds for immediate removal from consideration or, if I have entered into a contract with Collier Home Care LLC, for immediate termination of that contract. I authorize Collier Home Care LLC to make any necessary inquiries and investigations into my education, references, or employment history. I further authorize, unless otherwise indicated on this application, the release of my information to Collier Home Care LLC by any of the schools, services, or employers listed on this application. I also hereby release from liability Collier Home Care LLC and its representatives for seeking, gathering, and using such information to make decisions concerning my status as an independent contractor for Collier Home Care LLC and all other persons or organizations for providing such information. THIS IS NOT AN APPLICATION FOR EMPLOYMENT. I understand and agree that if this application is accepted, my status will be that of an independent contractor and as such, I will be solely responsible for all tax liabilities pertaining to monies received in the course of services I perform. (PLEASE TYPE YOUR NAME IN THE BOX BELOW TO CERTIFY THAT YOU UNDERSTAND AND AGREE, OR TYPE "YES", OR "AGREE").

Q.) Applications are considered for all independent contractors, and all contractors are treated during the agreement without regard to race, color, religion, sex, national origin, age, disability, or any other prohibited basis of discrimination as provided under applicable state and federal law. If I am retained by Collier Home Care LLC as an independent contractor I will: • Not be entitled to workers compensation benefits. Be obligated to maintain liability/malpractice insurance. • Not be entitled to unemployment insurance benefits unless unemployment coverage is provided by me or some other entity. • Be obligated to pay federal and state income tax on any moneys paid pursuant to the contract relationship. I represent and warrant that I have read and fully understand the foregoing, and that I seek to become an independent contractor under these conditions. (PLEASE TYPE YOUR NAME IN THE BOX BELOW TO CERTIFY THAT YOU UNDERSTAND AND AGREE, OR "YES", OR "AGREE").

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions

* Caregiver Signature