Independent Contractor Application

Applicant Contact Information

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone:

Phone #2:

Email:

 

 

 

 

Personal Information

Social Security No.

Are you legal to work in the U.S.?

Yes  No

Are you a Citizen?

Yes  No

Are you a resident or have a work permit?

Yes No

Drivers License No.

Do you have a valid drivers license?

Yes No

Date of Birth:

Do you have a reliable vehicle?

Yes No

Have you ever been convicted of a felony? Yes  No If yes, please explain:

 

 

Pleas sign this portion of your application signifying your acceptance to allow Grove Pet Service to request a background investigation on you. You allow Grove Pet Service to use personally identifiable information to collect background information.

 

                             

Sign                                                                                                    Date

 

 

Availability

What date will you be available to start?

Can you work weekends?

Yes No

Can you work evenings? (after 5pm)

Yes  No

Can you work overnight stays?

Yes No

How many miles are you willing to drive?

Can you work holidays?

Yes No

How many hours can you work per week?

Can you work flexible hours?

Yes No

Please indicate any special requests regarding your availability: (special holidays, etc)

 

 

Please indicate your availability (check): Early Morning (7:30am – 9:30 am) Morning (9:30 am -11:30 am) Afternoon (11:30am-5:00pm) Evening (5:00 pm-8:00 pm) Overnight (8:00pm – 8:00 am).

 

Monday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

Tuesday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

Wednesday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

Thursday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

Friday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

Saturday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

Sunday:

 Early Morning

 Morning

 Afternoon

 Evening

 Overnight

 

Education History

 

Name & Location

Number of Years completed

Did you graduate?

Subject(s) Studied and Degree(s) Received

High School

 Yes   No

College

 

 Yes   No

Other

 

 Yes   No

 

Employment History

Employer:

Dates Employed:

Position Held:

Salary/Wage:

Address:

Phone:

Supervisor:

Can we contact?

Yes  No

Reason for leaving?

Employer:

Dates Employed:

Position Held:

Salary/Wage:

Address:

Phone:

Supervisor:

Can we contact?

Yes  No

Reason for leaving?

References

Please list three personal references. Do not list family members.

Name:

Relation:

Phone:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

 

Special Skills and Experience

Please use this space provided to explain why you would be good for this position. Include any special skills or experience as they relate to the position you are applying for.

 

 

It is the CompanyÕs policy to make all Independent Contractor decisions without regard to age, race, color, religion, national origin, sex, disability, veteran status, marital status or any other protected status in accordance with local, state or federal law.

 

I certify that all information given by me on this application in is correct, true and complete.  I understand that falsification of any information on this application may be considered sufficient cause to cancel further consideration of this application, or immediate discharge from service.

 

I understand that if I am contracted, I am free to end the Independent Contractor relationship at any time for any reason.  However,  the company also reserves its right to terminate the Independent Contractor relationship at any time, for any lawful reason.

 

I understand that if I am contracted, I will be required to provide proof of identity and legal authority to work in the U.S.A.

 

I certified that I have read, fully understand and accept all the terms of the Independent Contractor application.

 

 

                             

Sign                                                                                                    Date