Brookline Community Aging Network

 

 Service Referral Program Application  

* required fields
Contact Name*:
Email Address*:
Phone Number*:
Web Site:
Company Name*:
Address:
  1. What are the services provided by your company?
    (This information will be provided to BrooklineCAN members as written below.)
  2. Please provide the following documentation/information:
    • A copy of your license/registration
    • Are your employees CORI checked?   Yes No Not Applicable
    • Professional background:
    • Professional affiliations:
  3. Are you available evenings and weekends? Yes No
  4. What is your hourly rate?
    (NOTE: Rate will not be associated directly with individual contractors, BrooklineCAN members will be given a range to aid in their decision making process.)
  5. Do you offer a senior discount? Yes No
    If yes, what is it?