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