Oconto County Senior Fall Prevention Contractor Application Survey

1.Please enter your name and contact information

First and last name

Phone number

Email address

Mailing address

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

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

3.Reference #1

First and last name

Relationship

Phone number

4.Reference #2

First and last name

Relationship

Phone number

5.Reference #3

First and last name

Relationship

Phone number

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

Yes

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

Yes

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

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

Yes

10.Do you wish to share anything else?

Oconto County Senior Fall Prevention Contractor Application

All information in this application is subject to disclosure.