Revised 10/2017

INDEPENDENT CONTRACTOR APPLICATION

POSITION APPLYING FOR:  DSP  Home Health Aide, 75hrs.  CAN Anything available to me

We are an Equal Employment Opportunity and Non-Discriminating Employer.

PERSONAL INFORMATION

______________________________________________________________________________________________
Legal name: Leonardo Last: Polanco
Middle Initial

3505 Blithe Ct Saint Cloud Fl

34772___________________________________________________________________________________________
___
Address: Street City State Zip code

Home Telephone: 203-671-6329_______________________________ Other Telephone:

_____________________________

E-mail: [email protected]_______________________________________ S.S. #

046-
Driver’s License #: P452-520-04-046- 06- - -
0____________________________________________ State:FL 6645
________________________

Are you a citizen of the U.S? ✅ Yes  No If not, are you authorized to work in the U.S.?  Yes  No

Have you ever been convicted of a felony?  Yes ❌ No

If yes, please explain: _________________________________________________________________________

_____________________________________________________________________________________________

Are you currently charged, excluded, suspended, debarred or otherwise ineligible to participate in federal
health care programs, including Medicare and Medicaid?  Yes ❌ No

Have you been convicted of a criminal offense related to the provision of health care items or services and
have not been reinstated in the federal health programs?  Yes ❌ No

Are you at least 18 years old? ✅ Yes  No

POSITION INFORMATION
Independent Contractor available schedule: Mon Tue Wed Thurs Fri Sat Sun Available
anytime, only time I’m not available is in the morning every Saturday until June.
***Please note that you are applying for an Independent Contractor 1099 position***
 Revised 10/2017
Hours Available: From: __________ to __________

How many hours are you willing to work?  Less than 20hrs. per week  More than 20hrs. per week
What shift are you willing to work? AM PM  Weekends ANYTIME

WORK HISTORY (Most recent first)

1. Job Title: Dairy Queen Duties: Back Grill, Front drive thru, Dealing
with money
Employer: Ryan Hobbs

Dates of Employment (01 / 2021)

From: 01/22

Starting Salary: $9.50 Ending Salary: $11.00  Full Time ✅Part Time  Temp
Employer’s Address: 2601 13th St

Supervisor: Ryan Hobbs May we contact? ✅ Yes  No Phone: N/A

Reason for Leaving:
PAY, Not as close to home

REFERENCE:

2. Job Title: Dollar General Duties: Money dealing, Heavy cleaning,

Customer Service and support
Employer: Louanne Wolfrom

Dates of Employment (01/ 2022)

From To: Current Job

Starting Salary: $10.50 Ending Salary $13.75  Full Time ✅ Part Time  Temp
Employer’s Address: 3865 Friars Cove Ln

Supervisor: Louanne Wolfrom May we contact? ✅ Yes  No Phone: +1 (407) 460-0457

Reason for Leaving:
Pay, no benefits

REFERENCE: N/A

3. Job Title: Duties:

Employer:

Dates of Employment (month / year)

From: To:

Starting Salary: Ending Salary:  Full Time  Part Time  Temp

Employer’s Address:
Supervisor: May we contact?  Yes  No Phone:
Reason for Leaving:

***Please note that you are applying for an Independent Contractor 1099 position***
 Revised 10/2017

REFERENCE:

❌ I have at least one year of experience working with children and/or adults with
developmental disabilities, in a medical, psychiatric, nursing or child care setting.

EDUCATION

Dates Degree Subjects Did you

Type of school Name and Location
Attended Received Studied graduate?
St Cloud High 08/15/19- Diploma Science, Yes
High School 6/17-23 Math,
History
College /
University
Graduate
School

Tech School

Other

Special courses, trainings or experience acquired, including military experience: ________________________

________________________________________________________________________________________________
________________________________________________________________________________________________

SKILLS
Clerical / Office skills Customers service, Communication, Organization
Yes No If so, please specify: well put into Word Document,
Computer skills ✅ PowerPoint

Languages ✅ English  Spanish  Other: _________________________
Heavy Lifting, Communication Skills, Leadership
Other skills

________________________________________________________________________________________________

CERTIFICATION & AUTHORIZATION

I hereby certify that all statements made in this application are true and correct to the best of my
knowledge. I understand that any misrepresentations or omissions of facts in this application are grounds
for disqualification from further consideration or for dismissal from Sub-Contractor employment.

I authorize the company to inquire into my educational, professional and past employment history
references as needed to research my qualifications for this position.

If hired, I agree to conform to the rules, regulations and policies of the company. I understand that I will be
a sub-contractor “at will” and either the company or I may terminate my sub-contractor relationship at any
time for any reason not in violation of law.

***Please note that you are applying for an Independent Contractor 1099 position***
 Revised 10/2017
I am aware that an Independent Contractor employment is contingent upon the satisfactory results
of reference checks, and both Local Law Enforcements and Federal Bureau of Investigation
Background Screening Checks.

I hereby acknowledge that I have read and fully understand the forgoing and seek a Sub-Contractor
employment under these conditions.

Leonardo Polanco _____________________________________________

____________________
Signature of Applicant Date 04/26/24

***Please note that you are applying for an Independent Contractor 1099 position***