Oconto County Senior Fall Prevention Contractor Application

All information in this application is subject to disclosure.

Oconto County Health & Human Services seeks to establish a pool of qualified contractors to assist the Senior Fall Prevention Program. The contractors will make minor home modifications and install equipment such as grab bars or hand rails in homes of program participants. If you are interested in learning more about the Senior Fall Prevention Program Click here!

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* 1. Please enter your name and contact information

First and last name

Phone number

Email address

Mailing address

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* 2. Please provide a description of your business, personnel, and services provided.

Please provide three professional references (name, phone number, and professional relationship)

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* 3. Reference #1

First and last name

Relationship

Phone number

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* 4. Reference #2

First and last name

Relationship

Phone number

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* 5. Reference #3

First and last name

Relationship

Phone number

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* 6. By selecting "yes" you authorize and give consent to undergo a complete background check.

Yes

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* 7. By selecting "yes" you agree to provide a completed W9.

Yes

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* 8. By selecting "yes" you agree to provide proof of insurance coverage (Certificate of Insurance) and copies of all applicable licenses and certificates for yourself and employees.

Yes

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* 9. Be selecting "yes" you herby acknowledge and understand that all information in this application is subject to disclosure.

Yes

Oconto County Senior Fall Prevention Contractor Application

All information in this application is subject to disclosure.

Question Title

* 1. Please enter your name and contact information

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* 2. Please provide a description of your business, personnel, and services provided.

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* 3. Reference #1

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* 4. Reference #2

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* 5. Reference #3

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* 6. By selecting "yes" you authorize and give consent to undergo a complete background check.

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* 7. By selecting "yes" you agree to provide a completed W9.

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* 8. By selecting "yes" you agree to provide proof of insurance coverage (Certificate of Insurance) and copies of all applicable licenses and certificates for yourself and employees.

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* 9. Be selecting "yes" you herby acknowledge and understand that all information in this application is subject to disclosure.

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* 10. Do you wish to share anything else?