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INDEPENDENT CONTRACTOR APPLICATION

265 SW Port St Lucie Blvd Suite 321, Port St Lucie, FL 34984


PO Box 827012 Pembroke Pines, FL 33082-7012
Phone (866) 665-3491 , Fax (772) 871-9296

Name: Date:
Last First Middle
Address
Street City State/Province ZIP/Postal Code

Telephone # ( ) Cell Phone # ( )

E-Mail Address:___________________ Referred to HILLC by:

In Home Support Companion Behavior Assistant Res Hab Supported Living

PCA Respite Type of employment desired Full-Time Part-Time

Date Available?_________________ Please specify days and hours:______________________________


If currently employed, may we contact your employer? Yes No

Rate of pay expected $____________per hour


Is there a specific reason you are applying to become an Independent Contractor at HILLC? Yes No

If yes, please briefly outline the reason:

Are you legally eligible to work in the U.S.? Yes No

Do you carry professional liability insurance? Yes No If yes, in what amount? _____________
Have you worked for Helping Individuals LLC(HILLC) before? Yes No

Have you ever been convicted, plead guilty or no contest to a crime (misdemeanor or felony? Yes No

If yes, please explain:

Do you have valid car insurance ? Yes No

Do you have a valid Florida Driver's License ? Yes No

Have you ever been disciplined by professional or state ethics or Licensing board? Yes No

Have you been in a car accident or recieved a moving violation in the last 3 months? Yes No

If hired as an independent contractor, will you agree to provide a Driver's record? Yes No

If hired as an independent contractor, will you agree to a criminal background Yes No


check?

Updated 6/5/10
EDUCATIONAL BACKGROUND

List previous three (3) educational institutions attended, beginning with the most recent

SCHOOL CITY STATE/PROVINCE GRADUATED? DEGREES EARNED

Yes No

Yes No

Yes No

List all licenses, certificates, or speiclaized trainings you have related to the position you are applying for:

Type Date of Most Recent Registration State Currently Vaild?

Yes No

Yes No

Do you have the following Training's?

CPR Yes No Date last certified:


First Aid Yes No Date last certified:
HIV/AIDS Yes No Date last certified:

Have you recently tested (last 12 months) negative for tuberculosis (TB)? Yes No

Have you been vaccinated against Hepatitis B? Yes No

PLEASE ANSWER THE FOLLOWING QUESTIONS:

What do you think is the most difficult part of caregiving?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

What was the best job you ever had and why?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

How will you be able to contribute to providing individuals with high quality care?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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Updated 7/3/10
EMPLOYMENT BACKGROUND
Provide the fol lowing information beginning with the most recent employer.

EMPLOYER TELEPHONE DATES SUMMARIZE THE TYPE OF WORK


EMPLOYED PERFORMED AND RESPONSIBILITIES
( ) FROM TO
ADDRESS

JOB TITLE HOURLY


RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND PHONE NUMBER $ per

REASON FOR LEAVING HOURLY


RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE? $ per

Yes No Later
EMPLOYER TELEPHONE DATES SUMMARIZE THE TYPE OF WORK
EMPLOYED PERFORMED AND RESPONSIBILITIES
( ) FROM TO
ADDRESS

JOB TITLE HOURLY


RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND PHONE NUMBER $ per

REASON FOR LEAVING HOURLY


RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE? $ per
Yes No Later
EMPLOYER TELEPHONE DATES SUMMARIZE THE TYPE OF WORK
EMPLOYED PERFORMED AND RESPONSIBILITIES
( ) FROM TO
ADDRESS

JOB TITLE HOURLY


RATE/SALARY
STARTING
IMMEDIATE SUPERVISOR AND PHONE NUMBER $ per

REASON FOR LEAVING HOURLY


RATE/SALARY
FINAL
MAY WE CONTACT FOR REFERENCE? $ per
Yes No Later

Please explain any gaps in your employment history:


__________________________________________________________________________________________________
__________________________________________________________________________________________________

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Updated 7/31/10
PROFESSIONAL REFERENCES

List name, relationship, years acquainted and phone number of three references (No relatives or personal friends please)

YEARS
NAME RELATIONSHIP PHONE NUMBER
ACQUAINTED

I certify that all the information I have provided is true, complete and correct.
I authorize HILLC to investigate all statements contatined on this application, I understand that any misrepresentation
or omission of facts cause for immediate disqualification and/or if engaged immediate dismissal.

I understand that if I am hired by HILLC, I will be required to provide a criminal background check, proof of identity and
legal authority to work in the United States, proof of certification or educational qualifications and a drivers record if
applicable.

This application does not in any way constitute a contract for employment or for the provision of services as
an independent contractor.

Applicant Signature: Date:

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Updated 7/31/10

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