Public Authority Registery Update Form – Fill Out and Use This PDF

PUBLIC AUTHORITY REGISTRY UPDATE FORM

1.Please print clearly and provide your CURRENT contact information. Check all boxes that apply. Please do not leave any sections blank.

Have you moved? Yes No If checked yes, please list the cities you are willing to work 20 miles from your home. Cities: _________________________________________________________________________________________

Home Address: ____________________________ Apt #______ City: _________________ Zip Code: _________

Mailing Address: ___________________________ Apt #_______ City: _________________ Zip code: _________

Phone Number (where clients can reach you): Home# ___________________ Cell # _______________________

Email Address: ________________________________________

I am NO longer working with Clients: ______________________________________________________________

2.I am not available to work for any clients at this time and DO NOT wish to have my name referred out because:

I have enough clients and would like to be placed as Fully Employed (I will be required to check in once every 3

If you checked one of the boxes in Question #2, PLEASE STOP HERE, SIGN, DATE AND RETURN THIS FORM. If not, please answer questions 3 and 4, Sign, date, and return this form.

3. Are you currently working for a client? If yes, how many ______. Please provide names of the clients.

4.I am available to work for Clients on (Please enter available days and times you wish to start working.)

MC 11/15/2018