Home Care Agency / PCA Employment Service Enrollment Form

This form will enable you to add your agency's information to the Newsletter and receive emails about Consumers who are searching for new Personal Care Assistants. To join this network, please complete the following form (to move from field to field please use the "TAB" key).

Agency Name
Contact Person
Title

Address1
Address2
Address3

Agency Phone
Agency Fax
Agency E-mail - Required

Agency fee structure:
No Employer Fee
Fixed Fee
Percent of Salary

Type of candidates referred:
Domestic / Homemaking
Personal Care / Home Health
Other Employees - Describe

Comments / Recommendations:




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CONSUMER DIRECTED SERVICES
Edward Litcher
540 Main Street, Suite B1314, Roosevelt Island, NY 10044
Phone: 718.233.3312
Fax: 718.233.3312

Email: elitcher@consumerdirectedservices.com