Download PDF of Contract Form
CONTRACT CATEGORY
Referral Service
Initial Assessment
Medication Management
Errand Runner
COMPANY NAME:
OFFICE ADDRESS:
Street Address:
Unit:
City:
State:
Zip:
Contact:
Title:
Phone 1:
Phone 2:
Mobile:
Fax:
Email:
Website URL:
PROFESSIONAL EXPERIENCE:
Scale of Operation
Global
Regional
Local
1 on 1
Years in Business
< 2
3 - 6
7 - 10
10 >
EXPERTISE
A:
B:
C:
D:
STATEMENT OF QUALIFICATIONS:
No.
Affiliated Agency
Professional Membership
Physicians
RNs
CNAs
Geriatrician
Pharmacy
Others
Certificates / Trainings
Valid Until (Mo/Year)
Assisted Living Management
Yes
No
Medication management
Yes
No
Business Administration
Yes
No
Dementia / Alzheimer
Yes
No
First Aid
Yes
No
Others (describe)
Yes
No
DESIRED FEE $:
Per Hour
Per Day
Per Project
AVAILABILITY:
Short Term
Immidiately
Two weeks Notice
Long Term
One month Notice
Other
ADDITIONAL DETAILS
(if any)
(Please attach Company brochure, Annual Report,
CV of key person/s, and any other relevant documents).
SINGNATURE:
Signature
Title
Date
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