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 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?

 

Support Disclaimer: Inclusion of services on this website does not represent a recommendation from the Brookline Council on Aging, the Brookline Senior Center, or the Brookline Community Aging Network.

Disclaimer: Inclusion of services through this program does not represent a recommendation or guarantee of work performance from the Brookline Council on Aging, the Brookline Senior Center, or the Brookline Community Aging Network. The user of this program therefore agrees to release the above named from any and all liability. The user should make whatever investigation or other resources that they deem necessary or appropriate before hiring or engaging Service Providers.