Contractor Application

Location *

Languages Spoken/Written/Understood (comma-separated: English, Spanish, Mandarin, Cantonese, others)

Where Do You Want to Be Assigned (comma-separated cities/areas)

First Name *

Last Name *

Contractor Aide/Nurse Type *

Social Security Number (123-45-6789) *

Birth Date *

Phone *

Email *

Street Address *

City *

State/Region/Province *

Postal / Zip Code *

Areas Covered *

Do You Have a Working Car/Automobile to Travel to Patient Homes? *

Work Desired

Days Available to Work Each Week (comma-separated) *

Education

Graduated from High School or GED Equivalent? *

GED/High School Diploma Completion Date

High School *

High School Address or City/State *

Graduated from College? *

College Completion Date

College or University Name

College or University Address or City/State

Employment History

Employer Name *

Employer Address or City and State *

Supervisor Name *

Supervisor Number

Date From (Employment) *

Date To (Employment)

Company Position *

Salary Amount or Hourly Rate (USD) *

Reason for Leaving *

References — List Two (2) Professional References

Reference 1 — Name *

Reference 1 — Address *

Reference 1 — Relationship *

Reference 1 — Years Known *

Reference 1 — Phone Number *

Reference 1 — Best Time to Call *

Reference 2 — Name *

Reference 2 — Address *

Reference 2 — Relationship *

Reference 2 — Years Known *

Reference 2 — Phone Number *

Reference 2 — Best Time to Call *

Emergency Contact

Emergency Contact Name *

Emergency Contact Address *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Are You Physically Capable of Performing the Duties of This Job Successfully? *

Have You Ever Been Arrested/Convicted for Any Crime Involving Violence, Carelessness, or Integrity? *

If Yes, Provide Details

Date Started

Background Check Authorization — I authorize LarCare Inc. & DBA SamariCare Services to conduct a criminal records check, drug testing, TB testing, and any other background checks deemed relevant, per the terms above.

I Authorize the Background Check Described Above *

Authorized Signature — Full Name *

Date-Time *

Signature — type your full legal name to sign *