Consumer - Employment Opportunity Form
To access the Network of Employment Services please complete and submit this form (to move from field to field please use the "TAB" key). As soon as this information is received and processed, it will be forwarded to the network members. Network members will in turn process your inquiry, and they or their clients will contact you directly. After you submit this information, please print a copy of the Confirmation Page for your records.
Consumer Information:
Name
Address1
Address2
Address3
Phone ...
Best Time
Fax
E-mail -
Required
Consumer's Age:
Younger than 21 . . . .
Between 21 and 30
Between 31 and 50 . . . .
Between 51 and 70
Older than 70
Consumer's Gender:
Female . . . .
Male
Preferred Agency Fee Structure:
Fixed Fee . . . .
Percent of Salary . . . .
Fee Negotiable. . . .
No Fee
Method of Providing the Employee's Salary and Benefits:
Home Care Agency . . . .
Self Pay
Type of Candidates Requested:
Domestic / Homemaking
Personal Care / Home Health
Other Employees - Describe
Candidate's Experience:
Children . . . .
Teens . . . .
Young Adults . . . .
Seniors
Paraplegia . . . .
Quadriplegia . . . .
Hemiplegia . . . .
Amputation
Ventilators . . . .
Wheelchairs . . . .
Lifters . . . .
Other Equipment
Mental Impairments/Alzheimer's Disease . . . .
Visual/Auditory Impairments
Special Diets - Describe
Languages - List
Candidate's Documentation:
Social Security Number . . . .
Proof of Identity . . . .
Recommendations
Proposed Schedule:
Daily Hours
. . . . Days Per Week
. . . . Start Time
- Describe
Proposed Salary:
Per Hour
. . or . . Per Day
. . or . . Per Week
Other Selection Criteria / Comments / Recommendations:
