Travel Agreement

(For ALL non-service applicants)

As a stipulation to apply with Broadway Home Care, it is required that you are able to travel to patients’ homes in the company’s service areas. This requires you to have your own form of reliable transportation. By signing this agreement, you are stating that you have your own transportation and are willing to travel to one of the following zones for work/cases. Please select one primary work location:

I am willing to travel 30 minutes or more for a case:* Yes: No:

I am willing to do live in cases (minimum case of 24 hours):* Yes: No:

  Johnstown Zone (Johnstown & Gloversville)
  Broadalbin Zone (Broadalbin, Mayfield, & Northville)
  Saratoga Springs Zone (Saratoga Springs, Gansevoort, Greenfield Center, Porter Corners, Middle Grove, & Rock City Falls)
  Waterford Zone (Waterford & Clifton Park)
  Mechanicville Zone (Mechanicville & Stillwater)
  Corinth Zone (South Glen Falls, Corinth, & Hadley)
  Ballston Spa Zone (Ballston Spa, Round Lake, Ballston Lake, Rexford, Burnt Hills, & Galway)
  Amsterdam Zone (Amsterdam, Hagman, & Fort Johnson)
  Schenectady Zone (Rotterdam Junction, Schenectady, Glenville, & Alplaus)

I understand that by signing this agreement I am stating that I have transportation and am able and willing to travel to one of these areas for work/cases

APPLICANT

COMPANY REPRESENTATIVE

Name * :

Name :

Signature *

Reset Signature

Signature

Reset Signature

Date:

Date :

Driver's License Verified (for non-certified applicants)


Travel Agreement (For ALL non-service applicants) As a stipulation to apply with Broadway Home Care, it is required that you are able to travel to patients’ homes in the company’s service areas. This requires you to have your own form of reliable transportation. By signing this agreement, you are stating that you have your own transportation and are willing to travel to one of the following zones for work/cases. Please select one primary work location:
I am willing to travel 30 minutes or more for a case:* Yes: No:
I am willing to do live in cases (minimum case of 24 hours):* Yes: No:

Johnstown Zone (Johnstown & Gloversville) Broadalbin Zone (Broadalbin, Mayfield, & Northville) Saratoga Springs Zone (Saratoga Springs, Gansevoort, Greenfield Center, Porter Corners, Middle Grove, & Rock City Falls) Waterford Zone (Waterford & Clifton Park) Mechanicville Zone (Mechanicville & Stillwater) Corinth Zone (South Glen Falls, Corinth, & Hadley) Ballston Spa Zone (Ballston Spa, Round Lake, Ballston Lake, Rexford, Burnt Hills, & Galway) Amsterdam Zone (Amsterdam, Hagman, & Fort Johnson) Schenectady Zone (Rotterdam Junction, Schenectady, Glenville, & Alplaus)

I understand that by signing this agreement I am stating that I have transportation and am able and willing to travel to one of these areas for work/cases

APPLICANT		COMPANY REPRESENTATIVE
Name * :		Name :
Signature * Reset Signature		Signature Reset Signature
Date:		Date : Driver's License Verified (for non-certified applicants)