Service Provider Application

Your Name (required):

Your Email (required):

Your Title (required):
Miss.Mrs.Ms.Mr.Dr,

Are you 18 years or older (required)?
YesNo

Home Address (required):

Street:
Apt:

City:

State:—Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zipcode:

Home Phone (required):

Cell Phone (required):

Social Security Number (required):

Can you provide evidence of your legal eligibility to work in the United States (required)? YesNo

What kind of job(s) do you want (required)?

When do you want to begin work (required)?

How well do you speak English (required)?A littleO.K.WellVery WellFluently

How well do you write English (required)? A littleO.K.WellVery WellFluently

Do you speak any other languages other than English (required)?YesNo

If "Yes," please specify:

What days of the week are you willing to work (required)?MondayTuesdayWednesdayThursdayFridaySaturdaySunday

How many hours per week are you willing to work (required)?5 hours or less5-15 hours15-30 hours30-45 hours45-60 hours60+ hours

What times of day do you wish to work (required)?

Are you willing to "live-in" your place of work (required)?YesNo

If "Yes," please click the days you're willing to "live-in":MondayTuesdayWednesdayThursdayFridaySaturdaySunday

What activities do you enjoy most?

Is there work you refuse to do (required)? YesNo
If "Yes," please describe:

Do you have any special requests, needs, or accommodations related to your work and work schedule (required)?YesNo

If "Yes," please describe:

What is your highest level of formal education (required)?No high school diplomaHigh SchoolVocational SchoolUndergraduateGraduatePh.DOther doctorate or professional degree

Name of school (required):

Address of school (required):

Field of Study (required):

Degree / Certificate (required):

Have you completed an apprenticeship or vocational training?YesNo

If you answered "Yes," the following information is required :

Name of organization / sponsor:

Address of organization / sponsor:

Degree / Certificate:

Do you have professional or occupational license (required)?YesNo

If you answered "Yes," the following information is required:

License number:

Field of Licensure:

State(s):

Are you currently enrolled in school (required)?YesNo

If you answered "Yes," the following information is required:

Name of school:

Address of school:

Field of Study:

How many credits, on average, each semester:

Type of degree / certificate expected:
Date when degree / certificate expected:

Do you have a professional or occupational certification (required)?YesNo
If you answered "Yes," the following information is required:
Certificate number:

Field of Certification:

State(s):

Do you have a driver's license (required)?YesNo

If "Yes," in what state(s):

Do you own, or have access to, a car (required)?YesNo

If you answered "Yes," is the vehicle currently insured and inspected?YesNo

Have you gotten a "ticket" for any violation other than parking in the past 3 years (required)?YesNo

If "Yes," please provide additional details:

If you do not own a car, what transportation do you use?

May we contact your references by phone, in writing, or by email and ask about your work with them (required)?YesNo

If we have your permission to contact your references, please provide contact information below.

Name and title of reference:

Your position:

Name of company or employer:

How long did you work there:

Telephone number of company:

Address of company:

Email address of reference:*

Name and title of reference:

Your position:

Name of company or employer:

How long did you work there:

Telephone number of company:

Address of company:

Email address of reference:*

Name and title of reference:

Your position:

Name of company or employer:

How long did you work there:

Telephone number of company:

Address of company:

Email address of reference:*

*Please make certain that your reference's email address will directly reach her or him.

If you wish to submit a cover letter you may upload it here:

If you wish to submit a resume you may upload it here:

Note: The Disability Know-It-All is a company that provides referrals to resources for people with physical disabilities. Our resources include independent contractors who provide personal service(s). This form is part of the process of application for consideration for a position as a service provider.

This form is one part of an assessment process that can lead to a well paid and respected position as a service provider.
Note:
• The Disability Know-It-All LLC is a company that provides information about physical disabilities and other issues, including referrals to service providers who are independent contractors and have the freedom to determine all lawful aspects of their work circumstances including, but not limited to, their schedules and fees.
• All references in this document to the Disability Know-It-All LLC include, but are not limited to, the company known as the Disability Know-It-All and all independent contractors, employees, associates and affiliates of the company, including its CEO and owner, Jacquelyn Volk. In this document, all references to the Disability Know-It-All include, but are not limited to, the company Disability Know-It-All LLC and the entities and individuals lawfully associated with the company.
• The Disability Know-It-All LLC disclaims all responsibility for personal or other liability, loss or risk that is directly or indirectly associated with your (the candidate/applicant) participation in the assessment and application process for a position as a service provider including, but not limited to, your submission of this application form.
• The use of the words “I” and “my” in the completion of this application form refer to the individual known as candidate and/or applicant who lawfully completes this application form and whose electronic signature is submitted to the Disability Know-It-All with this application form.
By completing this Service Provider Application, you agree to the terms below and you affirm that :

• I read the entire service provider application.YesNo

• I understand the application as it is written in English.YesNo

• I completed the application by myself.YesNo

• All of the information that I have provided is true and complete to the best of my knowledge.YesNo

• Where permitted by law, I authorize the Disability Know-It-All LLC to investigate all of the statements I have made in this application, and I release the Disability Know-It-All LLC from any personal or other legal liability, loss or risk that is directly or indirectly associated with making such investigation and in using my statements in their assessment of my qualifications for the position of a service provider.YesNo

• Where permitted by law, I authorize the Disability Know-It-All LLC to conduct a general background check about me, and I release the Disability Know-It-All LLC from any personal or other legal liability, loss or risk that is directly or indirectly associated with conducting this general background check and in using the information obtained through this background check in the assessment of my qualifications for the position of a service provider.YesNo

• Where permitted by law, I authorize the Disability Know-It-All LLC to conduct a criminal background check about me ,and I release the Disability Know-It-All LLC from any personal or other legal liability, loss or risk that is directly or indirectly associated with conducting this criminal background check and in using the information obtained through this criminal background check in the assessment of my qualifications for the position of a service provider.YesNo

• I authorize the Disability Know-It-All LLC to obtain all lawful written and verbal information about me from the references submitted in this application, and I release the Disability Know-It-All LLC from any personal or other legal liability, loss or risk that is directly or indirectly associated with making such inquiries and in using the information obtained from my references in the assessment of my qualifications for the position of a service provider.YesNo
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By submitting this application electronically, I affirm that I have completely answered all questions truthfully and to the best of my knowledge.