New Caregiver Registration Form
Anchor Homecare
Caregiver Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Gender
*
Male
Female
SSN
*
Date of Birth
*
-
Month
-
Day
Year
Date
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Who will you be working for?
*
Caring for a loved one?
Agency Client
Please add a personal reference:
*
Full Name
Contact Number
1
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Agency Caregiver Information
If you are working with an Agency Client, or open to picking up another case(otherwise skip this section)
Applying as a CG for an Agency Client
*
Yes
No
Willing to do both
Are you available to work right away
Yes
No
Will you work with Children
Yes
No
Will you work with pets?
Yes
No
Will you work with smoking in the home?
Yes
No
Do you drive?
Yes
No
What Languages do you speak?
English
Spanish
Russian
Arabic
Other
What days of the week are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Woul you like to enroll in Direct Deposit?
*
Yes
No
Type of Account
Checkings
Savings
Name of Bank
Account Number
Routing Number
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MI LOGIN ACCOUNT INFORMATION
Please search on Google for MI LOGIN FOR BUSINESS- https://milogintp.michigan.gov/eai/tplogin/authenticate?URL=/ (please make sure you are going to MI LOGIN FOR BUSINESS and not the regular MI LOGIN)
Username
*
Password
*
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Should be Empty: