Sitters, LLC

Independent Contractor

Please fill out this form completely, and then click on the "Submit" button to send the information to us. We will review your submission and contact you as necessary.

Applicant Information

First Name:

M.I.:

Last Name:

Date of Birth:

Street Address:

Apartment/Unit #:

City:

State:

Zip:

Phone:

Cell/Alternate Phone:

Date Available:

Position Applied For:

Adult

Children

Hospital

Church (nursery)

Group

Cleaning

Are you a citizen of the United States?

Yes

If no, are you authorized to work in the U.S.?

Yes

Have you ever worked for this company?

Yes

If so, when?

Have you ever been convicted of a felony?

Yes

If yes, explain

What hours are you available?

Days: From

To:

Nights: From

To:

Areas of Experience

Elder Care

yrs.

Child Care

yrs.

Cleaning

yrs.

Education

High School

School Name:

Address:

From:

To:

Did you graduate?

Yes

Degree:

College

School Name:

Address:

From:

To:

Did you graduate?

Yes

Degree:

References

Please list three personal references. NO RELATIVES

Reference 1

Full Name

Relationship

Company

Phone

Address

Reference 2

Full Name

Relationship

Company

Phone

Address

Reference 3

Full Name

Relationship

Company

Phone

Address

Previous Employment

Employer 1

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference

Yes

Employer 2

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference

Yes

Employer 3

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference

Yes

Special Skills & Certifications

CNA

LPN

CPR Child

Other-please specify

License/Certification No.

Other Special Skills/Training

Disclaimer and Certification

By clicking on the "Submit" button, I certify that my answers are true and complete to the best of my knowledge. Further, I hereby authorize the agency to obtain any information related to past employment, background check, medical records, etc. for the purpose of application evaluation. If this application leads to a contract, I understand that false or misleading information in my application or interview may result in my release.

Please print the attached form and fax it to our office.

Cindy Yelverton, Owner

Jackson, MS
P.O. Box 12597
Jackson, MS 39236
601-981-3661

Oxford, MS
662-259-2401
or 601-291-6555

Independent Contractor

Applicant Information

Education

References

Previous Employment

Special Skills & Certifications

Disclaimer and Certification

Cindy Yelverton, Owner

Care is our calling