Application For Contract
Application For Contract
Contractor Address *
Contractor Address
City
State/Province
Zip/Postal
Have you ever applied as a Contractor with us? *
Are you legally eligible for employment in the United States? *
Have you ever been convicted of any crimes in the past ten years, excluding misdemeanors? *
High School *
Did you Graduate High School *
College *
Did you Graduate/Finnish College *
VO Tech *
Did you Graduate/Finnish VO Tech *

APPLICANT'S SIGNATURE

Please read and understand this statement before signing your application.

The information I have provided in this Application for Registration is true, correct and complete. False incomplete or misrepresented information of any kind will be sufficient cause for immediate termination of my employment.

I fully understand and accept all terms and conditions in the above statement.

I authorize Heartland Registry to contact and obtain information about me from previous employers, educational institutions and “references” I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

This application is not a contract agreement. I understand and agree that I will work as an Independent Contractor and that I am responsible for my federal tax obligations, including any required payments for self-employment estimated taxes. I understand that Heartland Registry will issue me an IRS form 1099 each calendar year.

I fully understand and accept all terms and conditions in the above statement.

Hoyer lift *
Wheelchair/Walker *
Able to transfer to and from *
Able to load and unload *
Hospital Bed *
Applying Prosthetics *
Slide board/Pull sheet *
Parkinson *
Dementia *
Alzheimer *
Turret's Syndrome *
CHF *
Kidney Disease/Dialysis *
Safety precautions related to dialysis shunt *
Decubitus Ulcers *
Paraplegic/Quadriplegia *
Feeding Tube Care *
Colostomy/Catheter Care *
Drain Site Care *
Maintaining NPO or I&O *
Nebulizer or 02 Concentrator *
Meal Preparation/Special Diets *
Pet Friendly/Afraid of dogs or cats *
Object to use of Medical Marijuana *
Cooking light meals *
Washing/Folding patient's laundry *
Light housekeeping *
Feeding a patient *
Denture Care/Hearing Aide care/ Application *
Incontinence Care/Changing Briefs *
Capable of driving in high traffic areas *
Willing to go on trips out of town *
Able to drive large vehicles (Vans/Trucks) *
Experienced working with patients of different cultures/language *
You may upload your resume if you like
Maximum upload size: 516MB