Company Name (*)

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Address (*)

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Zipcode (*)

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Main Phone Number (*)

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Cell Phone

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Emergency Phone (*)

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Fax

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Contact Person (*)

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Title (*)

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Email Address (*)

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Website

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Describe the services that you would provide: (*)

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Describe your experience and length of time providing these services: (*)

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Do you use subcontractors or independent contractors for any of your services: (*)
YesNo
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What are your hours? If applicable, are you available after hours for emergency calls? How do you handle emergency calls: Please explain. (*)

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List the types of equipment you have to perform the services you provide: (*)

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Describe your experience and/or willingness to work closely and sensitively with older adults. (*)

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How do you currently screen prospective employees with regard to criminal background checks? Do you conduct periodic checks thereafter (annual or otherwise)? (*)

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How much liability insurance (or comparable) does your company maintain? (*)

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Do you carry workers’ compensation insurance? NOTE: If accepted as a SFV service provider you will be expected to provide a certificate of insurance documenting insurance coverage. (*)

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What applicable local/state/federal licenses does your company hold? (*)

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Specify the way you determine the rates for your services, such as time and materials, price per hour, fixed price for the season, etc. (*)

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Are you willing to offer members of San Francisco Village a discount? Please explain. (*)

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re you willing to respond to request for services from members of San Francisco Village within 24 hours? (*)

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Do you know of any service providers you would like to recommend to SFVN who provide services to enable seniors to remain in their own homes as they age? Please provide phone numbers and email address. (*)

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Please list three individuals (name and daytime telephone number) who have used your services and who can recommend your company: (*)

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