Date Format: MM slash DD slash YYYY
Name, address, phone, email. If no changes to your contact information, please write, "No changes".
Name and hours of the consumer you are working for.
These are approximate time periods and are not specific times you would be working or are obligated to work, it is an indicator to a span of time you are available.
This area is to be completed only if days or time vary for your availability or there is other specialized information you wish for us to have regarding your availability
Select either of these areas in regards to varying degrees of availability.
Please let us know if you have questions and would like us to contact you.
Your information will be updated and remain confidential to only members of the NICIL Home Service Program. Just a reminder you need to update monthly either here, on our website, or via phone, email, or fax. Without a monthly update, you will be removed from the NICIL Registry.