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Home Maintenance Broker Application Form

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Enter your phone number Enter a valid number like +1555-123-4567
Enter your phone number Enter a valid number like +1555-123-4567
Enter an email Use an address with (@) and (.)
What is your preferred method of communication
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Enter your phone number Enter a valid number like +1555-123-4567
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How did you hear about H-NCSSS?
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Do you speak any languages other than English?
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What is your current situation?
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Availability: Mornings
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Availability: Afternoons
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Availability: Evenings
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Availability: Occasionally
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Interests: What type of home maintenance are you able to provide for clients? (please check all that apply)
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Tools & Equipment: Do you have your own?
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Please select which items you have that you are willing to use for clients
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Locations: Which areas are you willing to provide services in?
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References: Please provide one professional and one personal reference, other than family members. References will be contacted by H-NCSSS staff.

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Enter your phone number Enter a valid number like +1555-123-4567
Enter your phone number Enter a valid number like +1555-123-4567
Enter an email Use an address with (@) and (.)
Enter an email Use an address with (@) and (.)
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Applicant Consent: I certify that the information in this application is accurate. I am willing to undergo a background check, which involves obtaining a police check. I understand that my application and all information contained herein will be held in strict confidence by Haldimand-Norfolk Community Senior Support Services Inc., and will not be released to any outside party.

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Consent to photographs / video taping / sound recordings: I hereby authorize Haldimand-Norfolk Community Senior Support Services Inc and any person authorized by it, to take and produce photographs, video tapes, sound recordings and any other audio, media coverage and/or visual reproduction for H-NCSSS.

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Confidentiality Agreement: As a volunteer of Haldimand-Norfolk Community Senior Support Services Inc., I will respect and maintain the confidentiality of information gained as a volunteer.

I also pledge to respect and maintain the confidentiality of individual personal information about persons who are clients, employees, or volunteers of H-NCSSS. At all times I will respect the privacy of clients and volunteers, their families, and other employees and volunteers.

I will ensure that private and confidential information is not inappropriately accessed, used or disclosed. I understand and agree to abide by the conditions outlined in this agreement which will remain in effect even if I cease to have an association with H-NCSSS.

I understand that such adherence is a condition of my volunteer work. I understand that a violation of this agreement may be grounds for termination as a volunteer.

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