Skip to content
“Family-Owned and Operated in Florida Since 2004”
[email protected]
BREVARD (321)413-0038
BROWARD (954) 929-4888
DADE (954) 929-4888
Google
Facebook-f
Linkedin-in
Quick Inquiry
Home
About
Services
Home Care Services
Personal Care Services
Companionship
Memory Care
Meal Preparation
Medication Reminder
Blog
Service Areas
Careers
Contact
Home
About
Services
Home Care Services
Personal Care Services
Companionship
Memory Care
Meal Preparation
Medication Reminder
Blog
Service Areas
Careers
Contact
Independent Contractor Application
Step
1
of
3
33%
URL
This field is for validation purposes and should be left unchanged.
Full Name
Date of Birth
MM slash DD slash YYYY
Address
Street Address
City
State
Zip
Phone
Email
Social Security#
Are you a US Citizen
Yes
No
Certifications
CNA
HHA
Companion
RN
Date of Certification
MM slash DD slash YYYY
Type of Shift(s) desired
Day‐time
Night‐time
Live‐in
Fill-in
Years of Experience
Allergies
Will you work with clients who have pets?
Dogs
Cats
Others
Specialized skills
What language(s) do speak other than English?
Do you have any physical limitations that would prevent you from performing the work for which you are applying?
Yes
No
If yes, please explain
Do you own a Car?
Yes
No
Driver’s License#
State
Exp Date
Insurance Co. Name
Phone
Policy#
Expiration Date
Work References (begin with most recent)
Company Name
Start & End Date
Contact Name/Phone
Duties
Add
Remove
Emergency Contact Information
Name
Phone
Relation
Address
Please Provide a Personal Reference (Not a Family Member)
Name
Phone
Years Known
Address
I voluntarily give CLASSIC HOMECARE, LLC the right to make a thorough investigation of my past employment. I agree to cooperate in such an investigation. I understand that my status as an Independent Contractor will be based in part on the accuracy of the information provided on this application.
Print Name
Signature of Applicant
Date
MM slash DD slash YYYY
Name
Date
MM slash DD slash YYYY
Are you available to work nights?
Yes
No
Are you available to work weekends?
Yes
No
Are you available to work 12hr shifts?
Yes
No
Are you available to work live‐in shifts?
Yes
No
Please list your availability below
Monday
Morning
Afternoon
Evening
Overnight
Tuesday
Morning
Afternoon
Evening
Overnight
Wednesday
Morning
Afternoon
Evening
Overnight
Thursday
Morning
Afternoon
Evening
Overnight
Friday
Morning
Afternoon
Evening
Overnight
Saturday
Morning
Afternoon
Evening
Overnight
Sunday
Morning
Afternoon
Evening
Overnight
Things that you like about your previous case/company
Things that could make your experience better or be improved from your previous case/company
Quick Inquiry
Facebook
This field is for validation purposes and should be left unchanged.
Name
Office
Brevard County
Broward County
Dade County
Phone
Email
Message
