Name*
First Middle Last
Address
Street Address City ZIP / Postal Code
Home Phone
Cell Phone
Alt. Phone
Email
Social Security #
Date of Birth
MM
DD
YYYY
Seeking referrals as
- HHA
- CNA
- LPN
- RN
HHA License #*
CNA License #*
LPN License #*
RN License #*
What days and hours are you available to work?
(Be Speciﬁc)
Will you work as a “Live-In” ?
- YES
- NO
How many days a week?*
Where are you willing to travel too?
(Be Speciﬁc)
Have you ever registered with Amerihome Health Care before?
If yes, please give dates
e.g 05/11/2015 - 17/18/2016
How did you hear of us?
Do you have a valid drivers license?
- YES
- NO
What State?
License #

High School
High School Name
State or Country
Graduate
- YES
- NO
College/Vocational School
College Name
State or Country
Graduate
- YES
- NO
Type of Degree
Degree

WORK HISTORY:

List present and past work related to home care, beginning with the most recent home care services you provided.
Work 1
Starting Date
MM
DD
YYYY
Ending Date
MM
DD
YYYY
Position
Name of Company or Client
Address of Company or Client
Phone Number
Reason for leaving
Type of work performed
Work 2
Starting Date
MM
DD
YYYY
Ending Date
MM
DD
YYYY
Position
Name of Company or Client
Address of Company or Client
Phone Number
Reason for leaving
Type of work performed
Work 3
Starting Date
MM
DD
YYYY
Ending Date
MM
DD
YYYY
Position
Name of Company or Client
Address of Company or Client
Phone Number
Reason for leaving
Type of work performed

Home Health Certificate
Date
MM
DD
YYYY
CNA Certificate
Original issue date
MM
DD
YYYY
Expiration date
MM
DD
YYYY
HIV/AIDS ins-service certificate
- Yes
- No
Domestic Violence in-service certificate
- Yes
- No
Upload File
Upload your HIV/AIDS ins-service certificate here
Upload File
Upload your Domestic Violence in-service certificate here
OSHA in-service certificate
OSHA Date
MM
DD
YYYY

(EXPIRES EVERY TWO YEARS)
Alzheimer’s Disease in-service certificate
- Yes
- No
Assisting with self-medication in-service certificate
- Yes
- No
Upload File
Upload your Alzheimer’s Disease in-service certificate here
Upload File
Upload your Assisting with self-medication in-service certificate here
Physical
Physical Date
MM
DD
YYYY

(not older than 6 months and must state “Free from communicable disease” or (no apparent signs or symptoms of communicable disease) NOT FROM A CHIROPRATOR
Valid C.P.R. card or Certificate dates
From
MM
DD
YYYY
To
MM
DD
YYYY
Liability Insurance
A Level II Background screening and clearance from AHCA prior to being placed on an assignment
Effective Date
MM
DD
YYYY

For 1 year
Palm Beach Badge #
(required for all HHA’s)
Document Upload
Upload
Drop files here or
Please upload the document on the list below
- Two employment references with a valid phone number and complete address
- Non-Expired Driver’s License
- Valid Auto Insurance
- Social Security Card, must be original
- Original Non-Expired Resident Alien Card or employment Authorization if you are not an American citizen. If you are US citizen you must provide proof via (Passport, Voter’s Registration or Birth Cert.)

Independent Contractor Registration Request

Step 1 of 4

High School

College/Vocational School

Type of Degree

WORK HISTORY:

Work 1

Work 2

Work 3

Home Health Certificate

CNA Certificate

OSHA in-service certificate

Physical

Valid C.P.R. card or Certificate dates

Liability Insurance

Document Upload