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Granny NANNIES Contractor Application
Personal Information
*First Name:
*Middle Initial:
*Last Name:
*Social Security Number
*Date of Birth
*Address Line 1:
Address Line 2:
Apt./Unit Number
*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:
*E-Mail:
*Emergency Contact Name:
*Emergency Contact Phone:
Position & Availability
*Have you ever worked for Granny NANNIES?
Choose a Have you ever worked for Granny NANNIES?
Yes
No
If Yes, which location?
Position applying for?
CNA
HHA
RN
OTHER
*Date available to start?
*Are you willing to work weekends?
Yes
No
Occasionally
*How far will you travel for a case?
Choose a How far will you travel for a case?
5 miles
10 miles
20 miles
+25 miles
Driving History
Granny NANNIES will be checking your driving history. Untruthfulness will cause you application to be immediately rejected.
Vehicle Year, Make, Model, & Color
DUI within last 3 years?
Yes
No
Reckless Driving within last 3 yrs?
Yes
No
Moving Violation(s) within last 3 yrs?
Yes
No
If Yes, how many Moving Violations?
If Yes, how many Moving Violations?
1
2
3
4+
Accidents within last 3 yrs?
Yes
No
If Yes, how many Accidents?
If Yes, how many Accidents?
1
2
3
4+
If Yes to any of the above, please explain:
Criminal History
Granny NANNIES will be checking your criminal history. Untruthfulness will cause you application to be immediately rejected.
*Felony conviction(s)?
Yes
No
*Theft related conviction(s)?
Yes
No
*Drug related conviction(s)?
Yes
No
*Violence related conviction(s)?
Yes
No
If Yes to any of the above, please explain:
Fitness Capability
*Have you ever been injured on the job?
Yes
No
*Can you stoop, bend & lift up to 25lbs?
Yes
No
*Ever recieved workman`s compensation?
Yes
No
If Yes, when?
If Yes to above, please explain injury and describe current physical status:
Education
Inaccurate information will delay the processing of your application.
*Diploma Received:
Diploma
Equivalency (GED)
Degree
None
College Name/Location:
Degree Earned:
Attended from:
Attended To:
Major/Minor:
Employment History (Last 3 Employers)
Inaccurate information (Example: wrong phone number) will delay the processing of your application.
Please notify your work references that a Granny NANNIES representative will be contacting them.
*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:
*Job Title:
*Reason For Leaving:
*Supervisor Name:
*Employer Phone:
*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:
*Job Title:
*Reason For Leaving:
*Supervisor Name:
*Employer Phone:
*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:
*Job Title:
*Reason For Leaving:
*Supervisor Name:
*Employer Phone:
Professional References
Please list three references that have personal knowledge of you.
Do not duplicate anyone used in the Professional Reference Section.
Inaccurate information (Example: wrong phone number) will delay the processing of your application.
Please notify your personal references that a Granny NANNIES representative will be contacting them.
*Reference Name:
*Relationahip:
*Phone:
*Reference Name:
*Relationahip:
*Phone:
*Reference Name:
*Relationahip:
*Phone:
Equal Opportunity Agency Policy
Granny NANNIES does not discriminate against applicants on the basis of race, color, religion, sex, national origin, political affiliation, sexual orientation, gender identity, marital status, disability and genetic information, age, membership in an employee organization, or other non-merit factor except as provided by law or when such requirement constitutes a bona fide occupational qualification necessary to perform the tasks associated with the position.
Background Authorization and Signature
I certify that all of the statements made in this application are true and correct, and that I have not misrepresented or withheld any information. I understand that the falsification of this information may result in immediate dismissal. I further acknowledge that any contract offered to me or which I accept is a contract at will and may be termainted by me or by the company at any time, with or without cause or reason. I understand that any offer of a contract may be contingent upon a background investigation which may include criminal, motor vehicle or previous employment. I hereby authorize all references and former employers listed on my application to give the company any and all information concerning my previous employment and any pertinent information they might have, personal or otherwise, and release all parties from any claims, causes of action, or liability from damages that may or could result from furnishing such information to the company.
*Choose One
Choose a Choose One
I Agree
I Disagree
*Name
*Enter Your Initials
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