APPLICATION FOR NEWBORN CARE PROVIDER
Let Mommy Sleep, LLC,
5161 I Ox Road, Fairfax Station, VA 22039
phone: 703.627.7225 844.MOM.BABY
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APPLICATION NOTE: This form is intended for use in evaluating your qualifications for engagement as an independent contractor to provide Newborn care services on behalf of the LLC. This is not an employment contract. Please answer all applicable questions completely and accurately. Any false or misleading statements during the interview process and on this form are grounds for terminating the process or, if discovered after the engagement begins, will be grounds for terminating the relationship. All qualified applicants will receive consideration and will be treated throughout their relationship with the LLC without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to engagement.
PERSONAL INFORMATION
Today’s Date: ____________________
Social Security Number: ____ ___ _______
Name: ________________________ _______________________ _____________________
Last First Middle
Current Address: ____________________ ____________________ ______ _____________
Street City State Zip Code
Home Phone ( ) ______________________
Cell Phone ( ) ________________________ email ________________________________
Emergency Contact Name and Phone Number: _______________________________________
How did you hear about our services? ______________________________________________
Why are you interested in working for us? ___________________________________________
____________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________
AVAILABILITY
Due to the nature of the business, no guarantee can be made as to the schedule of amount of hours worked .
1) When are you available to begin work?________________________________
2) In what geographical areas are you available to work? _____________________
_________________________________________________________________
3) What limitations do you have as to availability? __________________________
4) What nights of the week are you able to work?______________________________
5) How many nights are you able to work? ____________________________________
6) Valid Drivers License # ______________ State ________________ Exp. _______
Auto Insurance Company ____________________ Policy # __________________
Agent Name. ________________________ Phone No. ______________________
Are you willing to provide service to a client with a pet? _______________________
Any restrictions as to type of pet? _________________________________________
EDUCATIONAL/TRAINING CERTIFICATION
Please provide your educational background beginning with the highest level of completion and proceeding through high school. Please include continuing education certificates or other certifications:
______________________________________________________________________________
ANY OTHER NEWBORN OR POSTPARTUM CARE EXPERIENCE YOU’D LIKE TO SHARE ? ______________________________________________________________________________
______________________________________________________________________________
WORK HISTORY
Please provide your Three (3) previous employers information, including your employer name and address telephone number and contact person; dates of employment and name of supervisor and duties; salary and reasons for leaving.
Most Recent: __________________________________________________________________
______________________________________________________________________________
Second Most Recent: ____________________________________________________________
______________________________________________________________________________
Third Most Recent:______________________________________________________________
TUBERCULOSIS (TB) TEST & VACCINATIONS
Have you had a test for Tuberculosis? If yes, date of the most recent test? _________________
Are you up to date on the TDap and MMR vaccines and this year’s flu shot? ________________
BACKGROUND
As a condition of any engagement, we are required to request your last three (3) prior residence information.
1, ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
REFERENCES
List two (2) professional and two (2) personal references. Your application will not be considered unless four (4) total references are provided. Please include telephone numbers, nature of relationship, number of years known. As we will contact these references, please notify them in advance.
Professional References:
1. _______________________________________________________________________
2. ________________________________________________________________________
Personal References:
1. ________________________________________________________________________
2. ________________________________________________________________________
CERTIFICATION AND RELEASE: I hereby certify that I have read and understand the applicant notice on page one and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge during engagement. I authorize the LLC and/or its authorized agents including consumer-reporting bureaus, to verify any information contained herein, including an y criminal history or motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons from any liability for any damage whatsoever for issuing this information. I release this LLC from any liability which might result from any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during engagement. If LLC policy requires, I am willing to submit to drug testing to detect the presence of any illegal drugs prior to and during any engagement.
I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT OR ENGAGEMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE ENGAGEMENT RELATIONSHIP BETWEEN MYSELF AND THE LLC IS ONLY SUBJECT TO THE TERMS CONTAINED A SEPARATE AGREEMENT ENTERED BETWEEN US AND THE CONTINUATION OR TERMINATION OF THAT RELATIONSHIP SHALL BE AS STATED IN SUCH AGREEMENT.
______________________________________ ________________________
APPLICANT SIGNATURE DATE