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Contractor Application
Personal Information
Social Security Number*
Date of Birth*
Today*
First Name:*
Middle Initial
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:*
Home Phone:*
Cell Phone:
Email:
Drivers License No:*
State:*
Expiration Date:*
Do you have your own vehicle?*
Yes
No
Sex*
Male
Female
Marital Status*
Married
Single
Are you a U.S. Citizen*
Yes
No
If not a citizen, list alien number:
Work Preference
Date Available*
Days you will work?
Physical conditions which may restrict your ability to perform tasks:
Types of positions you will consider:
7 Day Live-In
Full Time
Part Time
Evening
Overnight
Weekend
I am willing to perform these tasks:
Light Ironing
Laundry
Change Linens
Run Family Errands
Grocery Shop
Assist with Bathing
Cook Meals
I can work in a home with:
Cats
Large Dogs
Any Dogs
None of the following
I drink alcohol:
Daily
Occassionaly
Never
I smoke:
Full Time Smoker
Occassional Smoker
Non-Smoker
Education
High School Name:
Location:
College or Trade School Name:
Location:
Degree Earned:
Attended from:
Attended To:
College or Trade School Name:
Location:
Degree Earned:
Attended from:
Attended To:
Major/Minor:
Related Knowledge/Skills
Florida Certifications:
CNA
HHA
Private Duty History- Provided Eldercare not Through an Agency
Name:
Employer Phone:
Job Description:
Dates:
Name:
Employer Phone:
Job Description:
Dates:
Name:
Employer Phone:
Job Description:
Dates:
Employment History
Name Of Employer:*
Address Line 1:*
Address Line 2:
City:*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:*
Employed From:*
Employed To:*
Employer Phone:*
Job Title:*
Supervisor Name:*
Job Description:*
Name Of Employer:
Address Line 1:
Address Line 2:
City:
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Employed From:
Employed To:
Employer Phone:
Job Title:
Supervisor Name:
Job Description:
Name Of Employer:
Address Line 1:
Address Line 2:
City:
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Employed From:
Employed To:
Employer Phone:
Professional References
Please list three references that have knowledge of your professional experience.
Reference Name:*
Address:*
Occupation:*
Phone:*
Reference Name:*
Address:*
Occupation:
Phone:
Reference Name:
Address:
Occupation:
Phone:
Background
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR A FIRST DEGREE MISDEMEANOR?
*
Yes
No
HAVE YOU EVER PLED NO CONTEST OR GUILTY TO A FELONY OR A FIRST DEGREE MISDEMEANOR?
*
Yes
No
HAVE YOU EVER BEEN TREATED FOR DRUG OR ALCOHOL ABUSE?
*
Yes
No
In Case of Emergency, contact:
Name:*
Relationship:*
Phone Number:*
I authorize American Care Group, Inc. to investigate all facts and statements contained in this application. I understand that misrepresentation or omission of pertinent facts is cause for termination without notice at any time. I authorize American Care Group, Inc. to release all information obtained through investigation and listed in this application to potential clients and authorize all previous employers to release full information to American Care Group, Inc.
Yes
No
Name:*
Date:*
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