• South Bay Home Health Care Agency

  413 E 211th Street Carson Ca 90745 Tel: 310 986 0008 Tel/Fax 310 522 4061

• CONTRACTOR APPLICATION/ AGREEMENT

• IMPORTANT: PLEASE READ

  Thank you for your interest in working as a caregiver for SOUTH BAY HOME HEALTH CARE AGENCY INC. Upon completing this form, you agree not to hold the agency or the clients/ patients responsible for any accidents that would happen in the workplace. You are responsible for your taxes/ social security as an independent contractor.

• Full Name
  First Name Last Name
• Address

  Street Address
  Street Address Line 2
  City	State / Province
  Postal / Zip Code	Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country

• Phone Number
  - Area Code Phone Number
• SSN/ TIN
• Drivers License No.
• Date of Birth
• Height
• Weight
• Age
• Status
  M S D W
• E-mail

• Please answer appropriately

• Type of Employment Desired
  Live in Live out
• Shift Desired
  AM PM
• How will you go to work
  I have car Someone can drive me By bus
• Salary Desired: Live in $
• Salary Desired: Hourly $
• Date Available
• Days/ Hours Available
• Last Employer
• Tel No.
• Do you have any experience as a caregiver
  Yes No
• How long
• Do you know how to cook
  Yes No
• How did you know about us
  Ads Friends/ relatives Employee
• If needed can you provide proof of legal authorization to work in the US
  Yes No

• Work Experience

• Do you have any experience taking care of patients with the ff conditions
  Alzheimer's Post Surgical Patient requires lifting Parkinson Hospice Stroke Dementia Diabetic Bipolar

• Employment History

• Date Employed
• Employer Name/ Address
• Tel No.
• Salary

• Training/ Education

• School Attended
• Course
• Location
• How long

• References

• Name (1)
• Address
• Phone No.
• Relation
• Name (2)
• Address
• Phone No.
• Relation
• Submit Form
• Should be Empty:

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Important Contact Person
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