Application For Contract Application For Contract If you are human, leave this field blank. PERSONAL Name: Last First MI * Date 1 * Contractor Address * Contractor Address Contractor Address Contractor Address City City State/Province Alabama Alaska Arkansas Arizona 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 State/Province Zip/Postal Zip/Postal Email * Contractor Phone Number * Have you ever applied as a Contractor with us? * Yes No If "Yes" describe in full * Position Desired * Are you legally eligible for employment in the United States? * Yes No Have you ever been convicted of any crimes in the past ten years, excluding misdemeanors? * Yes No If "Yes" describe in full * Other special training or skills (languages, medical equipment, certifications etc.) * EDUCATION High School * Yes No GED Name and location of High School? * Did you Graduate High School * Yes No College * Yes No Name and location of College? * Course of Study College * Number of Years College * Did you Graduate/Finnish College * Yes No VO Tech * Yes No Name and location of VO Tech * Course of Study VO Tech * Number of Years VO Tech * Did you Graduate/Finnish VO Tech * Yes No EMPLOYMENT Current or last Company Name * Telephone 1 * Address current or last * Employed from Date-to-Date 1 * Name of Supervisor 1 * Weekly Pay Start and Last 1 * Job Title and Describe your Work 1 * Reason for Leaving 1 * Next Company Name 2 * Telephone 2 * Address 2 * Employed from Date-to-Date 2 * Name of Supervisor 2 * Weekly Pay Start and Last 2 * Job Title and Describe your Work 2 * Reason for Leaving 2 * Next Company Name 3 * Telephone 3 * Address 3 * Employed from Date-to-Date 3 * Name of Supervisor 3 * Weekly Pay Start and Last 3 * Job Title and Describe your Work 3 * Reason for Leaving 3 * PERSONAL REFERENCES Name 1 * Address 1 * Phone No. 1 * Name 2 * Address 2 * Phone No. 2 * Name 3 * Address 3 * Phone No. 3 * 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. Signature Date * Signature * Clear PROFICIENCY TABLE CONTRACTOR NAME: * DATE: * ORTHO EQUIPMENT Hoyer lift * Yes No Some what Wheelchair/Walker * Yes No Some what Able to transfer to and from * Yes No Some what Able to load and unload * Yes No Some what Hospital Bed * Yes No Some what Applying Prosthetics * Yes No Some what Slide board/Pull sheet * Yes No Some what DISEASE PROCESSES Parkinson * Yes No Some what Dementia * Yes No Some what Alzheimer * Yes No Some what Turret's Syndrome * Yes No Some what CHF * Yes No Some what Kidney Disease/Dialysis * Yes No Some what Safety precautions related to dialysis shunt * Yes No Some what Decubitus Ulcers * Yes No Some what Paraplegic/Quadriplegia * Yes No Some what Feeding Tube Care * Yes No Some what Colostomy/Catheter Care * Yes No Some what Drain Site Care * Yes No Some what Maintaining NPO or I&O * Yes No Some what Nebulizer or 02 Concentrator * Yes No Some what Meal Preparation/Special Diets * Yes No Some what Pet Friendly/Afraid of dogs or cats * Yes No Some what Object to use of Medical Marijuana * Yes No Some what GENERAL CARE Cooking light meals * Yes No Some what Washing/Folding patient's laundry * Yes No Some what Light housekeeping * Yes No Some what Feeding a patient * Yes No Some what Denture Care/Hearing Aide care/ Application * Yes No Some what Incontinence Care/Changing Briefs * Yes No Some what Capable of driving in high traffic areas * Yes No Some what Willing to go on trips out of town * Yes No Some what Able to drive large vehicles (Vans/Trucks) * Yes No Some what Experienced working with patients of different cultures/language * Yes No Some what You may upload your resume if you like Drop a file here or click to upload Choose File Maximum upload size: 516MB Submit
