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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:*

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:
3-4 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:*

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:

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:

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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