INQUIRY FOR SERVICES FOR CHEBEAGUE CARES

  DATE _____________________________

 PERSONAL INFORMATION

¯  NAME OF PERSON COMPLETING INQUIRY________________________________ 

 

¯  NAME OF POTENTIAL CANDIDATE______________________________________

 

 

¯  FULL ADDRESS________________________________________________________

___________________________________________________________________________

¯  PHONE NUMBER________________________________________________________

¯  CELL NUMBER________________________________________________________

¯  EMAIL ADDRESS ______________________________________________________

¯  TENTATIVE START DATE OF SERVICE_________________________________

¯  TENTATIVE AMOUNT OF HOURS DESIRED_________________________________

 

 

 

PLEASE PROVIDE THE NAMES OF ANYONE WE ARE ABLE TO SPEAK WITH ON YOUR BEHALF

 

 

 

CLIENT SIGNATURE____________________________DATE________________________

 

For Any Questions feel free to contact Amy Rich icadmin@chebeague.net or Randi Bento icrcenter@chebeague.net or CALL 207-846-5610