Staff Registration

Información Personal

Personal Information

Profile Image

First Name

Middle Name

First Last Name

Second Last Name

Phone

Residential Address (Line 1)

Residential Address (Line 2)

City

State

Zip Code

Expected Hourly Rate

Birthdate

Social Security Number (SSN)

Has SSN?

Yes No

SSN Document Attachment:

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Allows uploading multiple files (JPG, PNG, PDF)..

Información Bancaria y Firmas

Bank Name

Account Type

Account Number

Routing

Screenshot of Banking Information:

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Allows uploading multiple files (JPG, PNG, PDF)..

Signature

Initials

Certificaciones y Entornos de Trabajo

What certification(s) do you hold? (check all that apply)

A) Licensed Electrician (Journeyman)

B) Apprentice

C) OSHA 10-Hours

D) None

Typical work environments (check all that apply)

A) Residential

B) Commercial

C) Industrial

D) Utilities / Power Generation

Medical Questionnaire

Sections A & B

Section A — Conditions

Severe Headaches

Yes No

Diagnosis date

Dizziness or fainting spells

Yes No

Diagnosis date

Seizures

Yes No

Diagnosis date

Epilepsy

Yes No

Diagnosis date

Anemia/Hemophilia/Other blood disorder

Yes No

Diagnosis date

Rheumatic Fever

Yes No

Diagnosis date

Diabetes

Yes No

Diagnosis date

Hypoglycemia

Yes No

Diagnosis date

Cardiac Disease

Yes No

Diagnosis date

High Blood Pressure

Yes No

Diagnosis date

Varicose veins or leg ulcer

Yes No

Diagnosis date

Thrombophlebitis (vein inflammation/blood clot)

Yes No

Diagnosis date

Thyroid problems

Yes No

Diagnosis date

Hay fever / Asthma / Respiratory disorder

Yes No

Diagnosis date

Chronic Cough

Yes No

Diagnosis date

Shortness of breath

Yes No

Diagnosis date

Chest pain

Yes No

Diagnosis date

Total deafness/hearing loss/ear problems

Yes No

Diagnosis date

Mental retardation/Learning disability

Yes No

Diagnosis date

Bloody sputum

Yes No

Diagnosis date

Eye/Vision conditions (glasses/contacts/color blindness, etc.)

Yes No

Diagnosis date

Hernia (rupture)

Yes No

Diagnosis date

Ulcers

Yes No

Diagnosis date

Kidney or Bladder trouble

Yes No

Diagnosis date

Hepatitis/Liver disease

Yes No

Diagnosis date

Parkinson’s Disease

Yes No

Diagnosis date

Skin problem/s

Yes No

Diagnosis date

Tuberculosis

Yes No

Diagnosis date

Alcoholism/Drug Addiction

Yes No

Diagnosis date

Positive PPD (TB skin test)

Yes No

Diagnosis date

Nervous breakdown/Mental illness/Psychiatric treatment or counseling

Yes No

Diagnosis date

Arthritis/Rheumatism

Yes No

Diagnosis date

Backaches

Yes No

Diagnosis date

Head injury

Yes No

Diagnosis date

Neck or Back injury

Yes No

Diagnosis date

Leg/Knee/Hip/Ankle injury

Yes No

Diagnosis date

Repetitive strain

Yes No

Diagnosis date

Arthroscopy of a joint

Yes No

Diagnosis date

Herniated (slipped) disc

Yes No

Diagnosis date

Surgical removal of a disc or spinal fusion

Yes No

Diagnosis date

Knee surgery

Yes No

Diagnosis date

Any fracture or broken bones

Yes No

Diagnosis date

Any other orthopedic surgery

Yes No

Diagnosis date

Amputation of a body part

Yes No

Diagnosis date

Chronic osteomyelitis (bone infection)

Yes No

Diagnosis date

Osteoporosis

Yes No

Diagnosis date

Residual disability from polio

Yes No

Diagnosis date

Muscular dystrophy

Yes No

Diagnosis date

Cerebral palsy

Yes No

Diagnosis date

Multiple sclerosis

Yes No

Diagnosis date

Ankylosing spondylitis

Yes No

Diagnosis date

Have you ever had Chiropractic Treatment(s)

Yes No

Diagnosis date

Complications of pregnancy

Yes No

Diagnosis date

Disorders of the immune system (optional answer)

Yes No

Diagnosis date

Elbow/Shoulder injury

Yes No

Diagnosis date

Wrist/Hand/Arm injury

Yes No

Diagnosis date

Are there any question(s) above that you do not understand?

Yes No

Diagnosis date

English

DISCLAIMER:
BGS value your privacy and are committed to protecting your personal information. Please be aware that, under certain circumstances, your information may be shared with third parties. This may include, but is not limited to, service providers, partners, or affiliates who assist us in delivering our services, complying with legal obligations, or improving contractor experience.

Additionally, you acknowledge and authorize the preparation and execution of Agreements, HIPAA compliance forms, W9 forms, and other regulatory or contractual documents necessary for lawful and efficient operations.

We do not sell or rent your personal data to third parties. Any third-party access to your information is governed by strict confidentiality and data protection agreements to ensure your information is handled responsibly and in accordance with applicable laws.

Acknowledgment
I acknowledge that I have read, understood, and agree to the terms outlined in the above disclaimer regarding the sharing of information with third parties. I understand that my personal or business information may be used for the preparation and execution of legal documents such as HIPAA, Agreements, W-9 forms, and other regulatory or contractual documents. I consent to the collection, use, and limited sharing of my information in accordance with applicable laws and the terms described.

Personal Information

Información Bancaria y Firmas

Certificaciones y Entornos de Trabajo

Medical Questionnaire

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