New Contractor Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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*Max. file size: 20 MB.Copy of Social Security Card*Max. file size: 20 MB.Proof of Health InsuranceMax. file size: 20 MB.Proof of Auto Insurance*Max. file size: 20 MB.Professional Liability*Attach copy of your Professional LiabilityMax. file size: 20 MB.Proof of LLCAttach copy of your Professional Liability. If you need to establish your LLC use this link: www.in.gov/sos/business/2428.htmMax. file size: 20 MB.Health InformationAs 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 PhysicalCopy of physical confirming that you are able to perform the essential functions of the job with or without restrictions, and free of communicable disease.Max. file size: 20 MB.Immunization RecordsCopy of Mantoux tuberculin skin test (required), Hepatitis vaccinations, Influenza shot. Please provide copies of any of these that you have.Max. file size: 20 MB.COVIDCopy of COVID Vaccination Card. Max. file size: 20 MB.COVID WaiverCopy of COVID waiver application and any supporting documentation. Max. file size: 20 MB.Drug ScreenCopy of 10-panel drug screen. Max. file size: 20 MB.CredentialsEducation*UniversityGraduation DateDegree CDR Number: Credentials*Certification/License or Related CredentialsState if applicable Attach resume Drop files here or Select files Max. file size: 20 MB. Attach business cardAs a contractor, please attach a copy of your business card. Drop files here or Select files Max. file size: 20 MB. Emergency ContactIn case of emergency at work please list your emergency contact person. Name First Last PhoneRelation to you DisclaimersI 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* MM slash DD slash YYYY
