Apply to join the Ashby Village Professional Service Provider Network

Referred by: » [Must be an Ashby Village member]
Organization or company name: »
Address1: »
Address2: »
City: »     Zip Code: »
Title:»
Contact person name FIRST • LAST: »•»
Phones MAIN • MOBILE • OTHER: »•»•»
Email: »
Web Address: »
Service Category:    Alternate Category:
Description of services (list all you are able to provide): »
Description of rates: »
List relevant insurances with $ amounts and carrier (including worker's comp, liability, and vehicle) »
List relevant California licenses and certifications, etc. in detail (e.g. contractors lic C-27 #555546) »
Length of time in business, and other information that might recommend your services to our members: »
Are you able to offer members a discount (please give details)? »
Please list three references, their daytime telephone number, and email (if known):
REFERENCE NAME PHONE NUMBER REFERENCE EMAIL ADDRESS
1) » » »
2) » » »
3) » » »
Are you bonded?  
Do you have experience working with elder individuals?  
Ashby Village's philosophy is that members always come first, and we strive to ensure prompt, excellent, compassionate service.  Additionally, we respect the confidentiality of personal member interaction.  We ask our providers to pledge the same philosophy of compassion, respect, quality work and reliability of service for our members.
I understand there is no cost to be on the list of professional Service Providers for Ashby Village.  I also understand Ashby Village will be receiving member evaluations upon work completed, and will update provider information annually.  By submitting this application, I agree to providing service to Ashby Village members sharing the same philosophy of compassion, respect, quality work and reliability.
In addition, I understand my contract for services is with the Ashby Village member, and not with Ashby Village.  Ashby Village serves as the broker for our members.
I agree: