Applicant Full Name
*
First Name
Last Name
Email
*
Home Street Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Number of years at this address
*
Mobile Phone
*
(###)
###
####
Daytime / Evening Phone if different from mobile
(###)
###
####
Social Security Number
*
Drivers License State
*
Driver’s License Number
*
Emergency Contact Name
Who should be contacted if you are involved in an emergency?
First Name
Last Name
Relationship to You
Emergency Contact's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact's Phone
(###)
###
####
4. If approved as an independent contractor, when would you be available to begin?
*
MM
DD
YYYY
5. Are you willing to work weekends?
Yes
No
If you answered NO above, please state limitations
6. Are you able to perform the essential functions of the job you seek with or without reasonable accommodation?
Yes
No
What reasonable accommodation, if any, would you request?
7. Have you ever been convicted of a felony or misdemeanor?
*
Yes
No
If You Answered YES above, please provide answers to the blanks in the description below
Yes, I was convicted of _________ on _________ (date) in _________ (city), ____ (state)
Yoga
Pilates
Massage Therapy
Meditation
Personal Training
Personal Training - Sports Performance
*Please list Sport(s): (Golf, Baseball, Football, Basketball, Hockey, Soccer, Lacrosse, Alpine/Nordic Skiing)
Pre/Post Natal Specialization
Youth Specialization
Seniors Specialization
Gyrotonics
Weight Loss/Management
Fitness Nutrition
Dietitian
Physical Therapy
Chiropractor
Post Rehabilitation
VO2 Testing
Water Therapy
Swim Instruction
Stretch and Flexibility
Trigger Point/SMR
High Intensity Interval Training
TRX Suspension Training
Rip Core
MMA
Boxing
Kettle Bell
Road Biking
Mountain Biking
Hiking
Tennis Coach
Ski Pro
Life Coach
Other (please describe)
Employer Name
Supervisor Name
First Name
Last Name
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Duties
Current or Reason for Leaving
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Employer Name
Supervisor Name
First Name
Last Name
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Duties
Current or Reason For Leaving
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Employer Name
Supervisor Name
First Name
Last Name
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Duties
Current Reason for Leaving
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
College/University Name and Address:
If you received a degree, enter it here
Other Training/Completion Date:
Please indicate any current Professional Licenses or Certifications that you hold:
Do you teach Group Fitness Classes? If yes, please list type and location:
How much experience do you have working one-on-one with clients in their homes, hotels, offices or outdoors?
Awards, Honors, Special Achievements:
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship
12. Please provide any other information you believe should be considered, including whether you are bound by any agreement with any current employer:
13. Do you have Liability Insurance?
*
14. Is your CPR/AED Certification current:
*
15. Please list the cities / towns where you are willing to work:
*
16. Do you have your own personal equipment for house calls?
*
If you have your own personal equipment for house calls, please describe:
