New Contractor | Nutrition Services

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Are you legally eligible for employment in this country?*

Yes
No

I-9 E-Verify: Will need copy of card(s) for I-9 E-Verify.*

Driver's License Number Social Security Number

Copy of Driver's License*

Copy of Social Security Card*

Proof of Health Insurance*

Proof of Auto Insurance*

Professional Liability*

Attach copy of your Professional Liability

Proof of LLC*

Attach copy of your Professional Liability. If you need to establish your LLC use this link: www.in.gov/sos/business/2428.htm

Health Information

As a contractor, you are responsible to provide items below at your own expense.

Are you able to perform the essential functions of the job with or without a reasonable accommodation?*

Yes
No

Physical

Copy of physical confirming that you are able to perform the essential functions of the job with or without restrictions, and free of communicable disease.

Immunization Records

Copy of Mantoux tuberculin skin test (required), Hepatitis vaccinations, Influenza shot. Please provide copies of any of these that you have.

Drug Screen

Copy of 10-panel drug screen.

Credentials

Education*

University	Graduation Date	Degree

CDR Number:

Credentials*

Certification/License or Related Credentials	State if applicable

Attach resume

Drop files here or

Attach business card

As a contractor, please attach a copy of your business card.

Drop files here or

Disclaimers

I agree to provide my own name badge with credentials.*

Yes
No

I agree to allow for a background check.*

Yes
No

I understand that I must obtain a Dietitian Certification/License or hold a Certification/License in good standing for the state in which I will work.*

Yes
No

The above information provided is true, correct and complete. As a contractor, any misstatements or omissions of fact may result in my cancellation of my contract.*

Date*