Address: 1701 North Market StreetShreveport, LA 71107Phone: (318) 671-8131Email: ilewis@nhilc.org Independent Contractor Work Request Name(Required) First Last Phone(Required)Email(Required) Requested Start Date(Required) MM slash DD slash YYYY Requested End Date(Required) MM slash DD slash YYYY Preferred HoursEstimated HoursService Needed(Required) Personal Care Companionship Meal Preparation Light Housekeeping Respite Other Tell us more about the services you need:Service Area/LocationTransportation(Required) Not Required Required Unsure Contractor Acknowledgment(Required) I AgreeI understand that submitting this form is a request for an assignment and does not guarantee work. I agree to accept only assignments within my qualifications and authorized services. PRIVACY NOTICE Do not include medical information, diagnoses, medications, Social Security numbers, insurance information, or other sensitive personal information on this form.
