INQUIRY
FOR SERVICES FOR CHEBEAGUE CARES
DATE _____________________________
¯ NAME OF PERSON COMPLETING INQUIRY________________________________
¯ NAME OF POTENTIAL CANDIDATE______________________________________
¯ FULL
ADDRESS________________________________________________________
___________________________________________________________________________
¯ PHONE NUMBER________________________________________________________
¯ CELL
NUMBER________________________________________________________
¯ EMAIL
ADDRESS ______________________________________________________
¯ TENTATIVE
START DATE OF SERVICE_________________________________
¯ TENTATIVE AMOUNT OF HOURS DESIRED_________________________________
PLEASE PROVIDE THE NAMES OF ANYONE WE
ARE ABLE TO SPEAK WITH ON YOUR BEHALF
CLIENT SIGNATURE____________________________DATE________________________
For Any Questions
feel free to contact Amy Rich icadmin@chebeague.net or Randi Bento icrcenter@chebeague.net or CALL 207-846-5610